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IN DEO CONFJDO. j fc

7kiO--i^ 0 e #* t/'Y/ ^

A TREATISE

ON THE HIDDEN NATURE,

AND THE

TREATMENT OF INTERMITTING

AND REMITTING FEVERS ;

ILLUSTRATED BY VARIOUS EXPERIMENTS AND OBSERVATIONS

IN TWO BOOKS;

BY JEAN SENAC, M. D.

TRANSLATED FROM THE LATIN, WITH NOTES,

BY CHARLES CALDWELL, M. D.

AND

A RECOMMENDATORY PREFACE.

BY BENJAMIN RUSH, M. D. &c.

PHILADELPHIA .-

PRINTED AND SOLD BY KIMBER, CONRAD, c? CO
NO. 93, MARKET STREET,

AND NO. 170, SOUTH SECOND STREET.

1805.

District of Pennsylvania, to zvit :

BE IT REMEMBERED, That on the twenty-fifth day of
October, in the thirtieth year of the independence of the United
States of America, A. D. 1805, Kimber, Conrad, & Co. of the said
District, have deposited in this Office, the Title of a Book, the right
whereof they claim as Proprietors, in the Words following-, to wit :

A Treatise on the hidden nature, and the Treatment of Intermit-
ting and Remitting Fevers, illustrated by various Experiments and
Observations : in Two Books ; by yean Senac, M. D. Translated
from the Latin, with Notes, by Charles Caldwell, M. D. and a re-
commendatory Preface, by Benjamin Rush, M. D. &c.

In conformity to the Act of the Congress of the United
States, intitled, " An Act for the Encouragement of Learning, by
securing the Copies of Maps, Charts, and Books, to the Authors and
Proprietors of such Copies during the times therein mentioned." And
also to the Act, entitled " An Act supplementary to an Act, entitled,
« An Act for the Encouragement of Learning, by securing the Copies
of Maps, Charts, and Books, to the Authors and Proprietors of such
Copies during the Times therein mentioned," and extending the bene-
tits thereof to the Arts of designing, engraving, and etching historical
and other Prints."

D. CALDWELL,

Clerk of the District of Pennsylvania.

Coil,

ROob
1905"

l*7Z/,

CONTENTS.

BOOK THE FIRST.

OF THE NATURE

OF INTERMITTING AND REMITTING FEVERS.

CHAP. I. Of the various kinds of Intermittents. - page 1
CHAP. II. Of the various causes of Intermittents as laid

down by certain medical writers. 7

CHAP. III. Of other and more probable causes. 12

CHAP. IV. Of the remote causes. - - 18

CHAP. V. Of the febrile rigor, or cold stage offerer. - 23
CHAP. VI. Of the effects of the cold stage of fever. - 30
CHAP. VII. Of the hot and sweating stages of fever. - 38
CHAP. VIII. Of the state of apyrexy or freedom from fe-
ver, which succeeds each paroxysm. ----- 47

CHAP. IX. Of the cause of the disappearance and recur-
rence of the fever at stated periods. 52

CHAP. X. Whether or not any thing can be deduced from
other morbid affections, or from the action of the various parts
of the body, to enable us to discover the cause offebrile periods. 60
CHAP. XI. Of the diversified action of the febrile cause 68

CHAP. XII. Of febrile affections, which, though differ-
ent from intermittents, assume their external appearance. - 75

CHAP. XIII. Of affections, the mask or external character
of which, is sometimes put on by intermittents that have degene-
rated from their own nature. - 81

CHAP. XIV. Of the malignant form of intermittents. - 89
CHAP. XV. Of the change of intermittents into remittents

and continued fevers. 99

CHAP. XVI. Various observations adduced in confirms
; ion of the foregoing opinions and doctrines. - - - 108

CHAP. XVII. Further observations, setting forth the va-
riety and danger of such fevers 113

CONTENTS.

CHAP. XVIII. Of the method of detecting or distinguish-
ing intermittents, when disguised under the mask or appearance

of other diseases. - 120

CHAP. XIX. Of the consequences to be apprehended from
the leading symptoms of the fevers under consideration. - - 126
CHAP. XX Of various affections attendant on intermittents. 135
CHAP. XXI. Of affections which remain after the febrile
form of the disease has been removed. - 142

CHAP. XXII. Of relapses in intermittents. 146

CHAP. XXIII. Of the morbid appearances discovered in the
dissection of the bodies of those that have died of intermittents. 152

BOOK THE SECOND.

OF THE TREATMENT

OF INTERMITTING AND REMITTING FEVERS.

CHAP. I. Of the difficulty of curing intermittents, and

wherein that difficulty consists. page 159

CHAP. II. Whether or not all intermittents are to be treat-
ed with the same remedies ? Whether or net when left to them-
selves, they terminate or come to a crisis spontaneously ? and
whether or not, an attempt should be made to cure them at their
very commencement ? - ------ 164

CHAP. III. Of blood-letting. 170

CHAP. IV. Of cleansing the primje viae. ... 176
CHAP. V. Of the use of purgatives. 184

CHAP. VI. Of the use of aperients. 190

CHAP. VII. At what time the remedies mentioned in
the foregoing chapters are to be administered. - - - 195

CHAP. VIII. Of the various methods of curing fevers,
and first, of the cure by means of sudorifics. ... 201
CHAP. IX. Of the mode of exhibiting sudorifics in the

cure of fevers. 206

CHAP. X. Of attempting the cure of fevers by specific
medicines : and, first, an inquiry 'what these specifics are, and

CONTENTS.

whether or not any emetics or cathartics arc to he considered as
such. 211

CHAP. XI. Whether or not a true febrifuge power reside in
certain sudor i lies, bitters, aperients, and other remedies. - 215

CHAP. XII. Of the cure by means of the peruvian bark. 223

CHAP. XIII. Of injurious effects produced by the peruvian
barf! - 229

CHAP. XIV. Of the precautions necessary to prevent mis-
chief in the administration of the peruvian bark. ... 235

CHAP. XV. Of the method to be adopted in the use of
the peruvian bark. 244

CHAP. XVI. Whether or not a quartan fever require a
mode of treatment peculiar to itself? 252

CHAP. XVII. Of impediments arising- from previous af-
fections of certain parts of the system, or from different tempera-
ments. - 258

CHAP. XVIII. Of impediments arising from the fever it-
self, from the injuries which it usually does to various parts of the
body, and from an improper mode of treatment. - - . 265

CHAP. XIX. Of the cure of fevers, which, having- ceased
for a time, recur again, and also of certain symptoms that usually

accompany them. 2r3

CHAP. XX. Of the cure of malignant intermittents. - 283

CHAP. XXI. Of the treatment of common remitting fevers,
and also of those of a malignant nature. .... 289

1 ' &£

^j0k ******

RECOMMENDATORY PREFACE.

THE following translation of Senac's trea-
tise, " De recondita febrium inter mittentium,
" turn remittentium natura, et de earum cura-
u tione," was undertaken by Dr. Caldwell, at
the request of the Subscriber. He has long
known it to be a judicious and useful work, and
has derived much assistance from it in his prac-
tice. He is happy in this opportunity of recom-
mending it to the students of medicine in the
United States, as peculiarly calculated to assist
them in forming just opinions, of the nature
and treatment of the summer and autumnal dis-
eases of our country.

BENJ. RUSH, M. D.

Professor of the Institutes and practice of Medicine,
and of Clinical practice in the University of
Pennsylvania.

June 29, 1805.

TO BENJAMIN RUSH, M. D.

PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE,

AND OF CLINICAL PRACTICE IN THE UNIVERSITY OF

PENNSYLVANIA.

DEAR SIR,

THE following translation of Senac's cele-
brated treatise, on the nature and treatment of intermit-
ting and remitting fevers, is inscribed to you, xvithout
your knowledge, because I am confident that had your
permission been asked, your modesty would have pre-
vented you from granting the request. Were any
apology necessary, on my part, for the liberty I have
taken, it could be easily found in the relation in which
you stand to the work. You first taught in your lectures
the important truths which have long lain concealed in
it, under the garb of the Latin language, and have also
been eminently instrumental in having them now stript
of this dark and dead covering, and clothed in the lan-
guage of the United States. Of the reality and use-
fulness of these truths, it is only an echo of public
acclamation, to say, that you are one of the ablest judges
now living, as well as their most distinguished and suc-
cessful teacher. These circumstances would be alone
sufficient to designate you, even in the public eye, as
the most proper and natural patron of the work.

But I am actuated, also, by other considerations,
which, though more private and personal in their na-
ture, are not with me less powerful in their operation.
These considerations, were they to be even rejected by
the judgment, would appeal to the feelings, and though

DEDICATION.

repulsed from the head, could never fail to gain admis-
sion to the heart.

During an intercourse of some continuance, particu-
larly during the term of my medical pupilage, and the
first years of my practice as a physician, I received from
you many acts of attention and courtesy,which as a young
man and a stranger in the place, impressed me deeply
at the time, and have still continued to be sources of
grateful recollection. Out of these civilities, obliga-
tions naturally arose on my part, which our relative
situation has not yet allowed me to cancel. It is even
possible, that an opportunity of cancelling them may
never occur. I must, therefore, beg your acceptance
cf this dedication as some acknowledgment of them,
accompanied by my sincere wishes for a long continu-
ance of your health, happiness, and useful labours. For
however grateful, in the evening of life, the otlum in
secessu honestum may be to a philosophical and con-
templative mind, I am unable to wish you such a re-
tirement. It is enough that we should be deprived of
your labours and services when you shall have gone to
enjoy the reward of them in a better world.

CH. CALDWELL.

Philadelphia, Oct. 23, 1805.

PREFACE,

BY THE TRANSLATOR.

THE following treatise on the nature and treat-
ment of intermitting and remitting fever, after having
lain for many years entombed in the catacomb of a dead
language, is now for the first time introduced to the
light, through the medium of a living one. Viewing
it in itself and in its several relations, it presents, as
the translator conceives, a well supported claim to the
attention and patronage of the physicians of the United
States. He, therefore, flatters himself that its recep-
tion among them will not be unfavourable, but that it
will be regarded as a valuable if not a necessary addi-
tion to most of their libraries. Besides containing much
matter calculated to interest the scientific and to in-
struct the practical physician, it is the production of a
character of great celebrity and worth. Indeed in what-
ever light it be considered, whether in relation to its
origin, its execution, or its object, it will be found alike
respectable, masterly, and useful. To such readers as
are pleased with slight biographical notices, a few re-
marks on the subject of its origin may not be unac-
ceptable.

PREFACE.

The name of Dr. Senac, the author of the work, is
deservedly enrolled among those of the most distin-
guished physicians of France. Though educated with
a view to holy orders, yet an early inclination which
nothing could resist, led him at length to the profes-
sion of medicine. He flourished in th reign of Louis
XV. and stood high in the estimation and favour of his
royal master. Besides being for a considerable length
of time first physician to that monarch, wThose favour-
ites were selected on account of their pre-eminence in
talents and worth, he had conferred on him the hono-
rary titles of Counsellor of State, and Superintendant
General of the mineral waters of the kingdom of
France. He was also elected to a seat in the Academy
of sciences at Paris, an institution choice and rigid be-
yond all others in its admission of members. Of these
several places and appointments he proved himself to
be even more than worthy, for it was always considered
that he was rather an ornament to them than they an
honour to him. He was one of those self-dependent
characters who shine not with borrowed light, but like
an electron per se, contain their lustre within them-
selves. He died in the year 1770, and was followed to
the grave by the regret of the literary characters of his
time, and the tears of thousands whose sufferings had
been often times alleviated by his skill. Besides the
present treatise, he left behind him " A treatise on the
causes of acids and the cure of the plague" " A trans-
lation of Heister^s anatomy" " Anexv course of chemis-
try, and " A treatise on the structure of the heart."
This latter work is the most extensive and weighty of
all his writings. It is said to have been the result of
twenty years application and enquiry. It is a work of

PREFACE.

great learning, and is considered by the anatomists and
physiologists of France, as a master piece for depth
and accuracy of research.

To the skill of the physician, the science of the phi-
losopher, and the learning of the scholar, Dr. Senac,
added the accomplishments of the gentleman, and even
the exquisite polish and elegance of the courtier. He
possessed, in an uncommon degree, the happy, but rare,
art of appearing to equal advantage and acquitting him-
self with equal effect, whether seated by the bed of
sickness, immured in his closet, or surrounded by the
splendid circles of a court. It is scarcely necessary to
add, that these various qualifications and excellencies,
which are so seldom united in the same person, secur-
ed to Dr. Senac for many years his choice of business
in the metropolis of France.

With regard to the real merit of the present work,
there can be little doubt but various and even opposite
opinions will be formed. For it is true that many phy-
sicians are too apt to make their own customary modes
of thinking and practising, the standard of truth and
excellence in others. Perhaps this is more particularly
the case with those, whose reading and enquiries have
been on too limited a scale to enable them to be even
tolerable judges.

The translator has no wish to forestall public senti-
ment on the present occasion. Nor, if he even had, is
he vain enough to fancy himself equal to such an un-
dertaking. It is one of the felicities of a free country
that public opinion is too independant to bow to the

PREFACE.

sceptre or submit to the controul of any individual. If,
however, it be admissible for him to offer a remark or
two on the subject, he will briefly observe, that he re-
collects no work in any language, which comprizes such
an extent and rich variety of general and practical in-
formation respecting the nature and treatment of inter-
mitting fever, as the treatise before us. It is one of
those rare productions in medicine, thatmay be denom-
inated a work of principle as well as fact. For our
author has shewn himself to be able not only to observe
and to collect, but also to digest, arrange, and general-
ize. Though the work contains here and there certain
fanciful points of doctrine and hypothesis, that are
known to be erroneous, and that have been long since
exploded, it bears no mark of having arisen from the
pen of either a theorist or a copyist. It exhibits every
where the strokes of a master if not of an original in his
profession. In composing it, Dr. Senac appears to have
had no pre-existing model in view. He described dis-
eases as he had seen them, and recommended that
practice which he had found most successful. Like
Hippocrates of Greece, Sydenham of England, and a
physician now living in the United States, whose mo-
desty would be offended were I to mention his name,
he took nature for his text-book and observation for his
interpreter, disregarding alike the theories of his prede-
cessors and the dogmas of the schools. Persevering
in this plan, he necessarily produced a work of fact
and experience, interspersed with much original re-
mark and forcible reasoning. He oftentimes, indeed,
refers to preceding writers, and speaks of them in terms
respectful and modest. But he quotes them rather for
their facts than their opinions; for what they have seen

PREFACE.

rather than for what they have thought. He does hom-
age to them no further than they appear to him to
have done homage to nature. With the genius, judg-
ment, and experience of Cleghorn, he has given a
much more general and complete treatise on Intermit-
tents than that able and excellent author attempted.
Cleghorn's celebrated treatise on the diseases of Mi-
norca has somewhat of alocaland circumscribed charac-
ter ; but the treatise of Senac is as general as the preva-
lence, and as varied as the nature, of Intermittents them-
selves. It describes them in all their forms, and un-
masks them in all their disguises.

In clothing this treatise in the English language,
the translator has had other objects in view, than that
of merely putting the physicians of the United States
in possession of one single work of merit. He wishes
to become instrumental in directing them to an impor-
tant source of information, to which he apprehends
they have hitherto paid but little attention. He al-
ludes to the medical writings on the continent of Eu-
rope. It is greatly to be lamented, that, owing to their
being published in Latin, or some foreign language not
much read in the United States, these writings have
had but a very limited circulation among us. For
what we know respecting them we are chiefly indebted
to British translations and British reviews. But this
is a kind of dependence neither useful nor honourable
to us as a literary people. It bespeaks a state of hum-
ble minority from which it ought to be our pride, as it
is certainly our interest, to endeavour to emerge.

The British physicians translate such foreign pub-
lications in medicine only, as are accommodated to the

PREFACE.

diseases of their own climate and country. But the
diseases of Great Britain are very dissimilar to those of
the united States. Nor do they bear a much nearer
resemblance to the diseases that prevail in many parts
of the continent of Europe. Medical publications
higly useful both on the continent of Europe and in the
United States, may, in a practical point of view, be
worth but very little to a physician in Great Britain.
It is scarcely to be expected, therefore, that we should
receive, through the medium of the British press,
those continental works in medicine, best accommo-
dated to the diseases of our own country. It is believ-
ed that the present translation of a work written in
France, and but very little known to the physicians of
Great Britain, will serve as a confirmation of the truth
of these remarks. Perhaps a spirit of national jealousy
and pride may have some influence in making the phy-
sicians of Great Britain undervalue and neglect the me-
dical writings of France and other nations.

Recent and melancholy experience convinces us,
that the United States and the southern parts of Eu-
rope are nearly allied to each other on the score of epi-
demic diseases ; for the same pestilential fever, arising
from the same atmospherical causes, has committed
the most deplorable ravages in both places. But, owing
to a different state and temperature of atmosphere,
both Great Britain and the more northerly countries of
Europe are exempt from this calamity.

Indeed if we compare the climate and summer tem-
perature of the United states with those of Spain, Por-
tugal, Italy, and some parts of France, we will be at
once convinced that these several countries must neces-

PREFACE.

sarily be marked b)' a very considerable similarity oi
endemic and epidemic diseases. But a like compari-
son between the United States and Great Britain, will
as readily convince us, that the diseases of these two
portions of the globe must be greatly dissimilar.

But our knowledge on the subject does not termi-
nate here. We are taught the same truths by a refer-
ence to medical writings. It is well known, that we
look in vain into British publications for accurate ac-
counts either as to the histories or modes of treatment
of our indigenous diseases of summer and autumn.
But this is not equally true with regard to certain con-
tinental publications. In them we find such state-
ments, particularly with respect to the histories of dis-
eases, as correspond precisely to our own observations.
This is, perhaps, more particularly the case with re-
spect to the medical writings of Italy and France.

It is not the intention of the translator, by anything
here advanced, to offer the least disrespect to the me-
dical character of Great Britain. On the contrary, he
is convinced that the physicians of that nation are
more enlightened than those of any other country of the
old world. But their actual experience in their pro-
fession is necessarily confined to such forms of dis-
ease as fall under their immediate observation. And
having no opportunity of witnessing those gigantic
and anomalous forms of intermittents and remittents,
that oftentimes occur in the United States, and in the
south of Europe, it is not to be expected that they
should be capable of either describing them accurately,
or teaching their proper mode of treatment. They

PREFACE.

are, no doubt, masterly physicians in the climate of
Great Britain, but very feeble and unsuccessful ones in
that of the United States. To treat our summer and
autumnal diseases conformably to the rules of practice
laid down in British publications, would, in many in-
stances, amount to but little less than licenced murder.
From these remarks, the reader will be sensible, that
some of the British West and East India writers are,
in a great measure, excepted. Yet even these do not
seem to have been conversant with forms of intermit-
ting and remitting fever precisely similar to those that
occur in our own country.

The translator will only add, that should the pre-
sent treatise meet with a reception corresponding to its
merit, it is his intention to submit to the American
press, translations of other valuable continental works
in medicine.

Philadelphia, 1

October 3d, 1805. 5

BOOK FIRST,

THE NATURE OF INTERMITTING

AND REMITTING FEVERS.

CHAPTER I.

Of the various kinds of Inter mittents.

AN intermitting fever is a disease which
alternately commences and terminates at a given
time, and is marked by regular and distinct
periods. On stated days, for instance, and at
stated hours of these days, a febrile rigor or chilly
fit occurs, and is succeeded by a hot stage, which
again gradually abates until it terminates in a
state of true apyrexy or intermission. But as
the duration of this intermission, or the inter-
vals of time between the recurrences of the
paroxysms of the disease are various, it has ac-
cordingly been distinguished by various names.
Thus, when the disease commences and termi-
nates every day, it is called a quotidian ; when
on alternate clays, a tertian ; and when on every
fourth day, a quartan.

Other forms of the disease are mentioned by
both ancient and modern writers, such as the
quintan, the sextan, the septan, and the nonan.
That quintans do sometimes occur cannot be
denied ; but the existence of the others is a mat-
ter of very great uncertainty. If the credit due
to the reports of certain celebrated physicians
prevents us from denying their existence alto-
gether, we must at least acknowledge that they
have been but rarely observed. Even with re-
spect to those diseases which assume such an.
appearance, there is ample ground for the admis-
sion of doubts. It may indeed accidentally
happen that some paroxysms fall on the sixth or
seventh day; but it can scarcely be admitted
that they pursue this course and observe these
periods with regularity for any length of time.

But however reasonable and specious these
observations may appear, I am unwilling that
too much reliance should be placed on them :
the course and operations of nature are very im-
perfectly understood : those things which we
consider as differing from her customs and laws,
are oftentimes found to be consonant to them :
paroxysms may occur on unusual days ; as the
febrile power can come into action every third
and fourth day, it ought not to be considered as
very surprising should it show itself every sixth
day. A patient may escape one or two pa-

roxysms of a tertian, in which case the disease
will appear like a quintan or septan. A similar
occurrence in a quartan will produce other varie-
ties in the type of the disease.

But it is asked, do these occurrences actually
take place ? Nor can the question be determined
with any degree of certainty. We will therefore
treat of those diseases only, that have a well de-
fined type, and that pursue a regular course.
The quotidian we will not rank among genuine
intermittents, because its nature is totally differ-
ent from theirs, as will be elsewhere demon-
strated.

The diseases which deserve above all others
to be denominated intermittents, are tertians
and quartans. From these arises almost every
other form that is marked with distinct periods,
such as the double tertian, and the double quar-
tan : of these the course and order of the pa-
roxysms are such, that their nature and com-
position are easily discovered.

When, for example, the disease comes on
and terminates every day, provided the pa-
roxysm be alternately lighter one day and severer
the next, it appears evident that there exist two
forms of fever, one consisting of lighter pa-
roxysms and the other of more severe ones.

Here the lighter paroxysms correspond to the
lighter, and the more severe to the more severe,
every third day, that is, in the order of the ter-
tian type. The disease, therefore, which at first
view appeared to be a quotidian is evidently
composed of two tertians.

The form and course of the double quartan
are still more easily detected. This disease, for
instance, begins and terminates at a given hour,
for two days in succession, and does not appear
on the third ; but, on the fourth and fifth again,
it recurs as at first. Hence between the first
and third paroxysms, and between the second
and fourth, there are intervals of two days each.
This is a composition or form of disease which
rarely occurs ; yet in the frequency of quartans
it does sometimes occur, as every physician of
extensive experience must be able to testify.

Triple tertians and quartans more rarely ap-
pear. The disease is called a triple tertian, when
three paroxysms occur in the space of two days,
one, for example, every sixteen hours. This
type was observed by Galen and Riverius, but
must be ranked among the unusual phenomena
of intermittents. More frequently two pa-
roxysms take place in one day, while the next
proves a clay of complete intermission : this
form of disease might be likewise denominated

a double tertian, since it consists in reality of two
fevers, which recur every third day.

As to the triple quartan, if the paroxysms
only be regarded, it cannot be distinguished
from the quotidian or double tertian : nor in-
deed have physicians observed any thing dif-
ferent in it, except the paroxysm that falls on
that day which, in the double quartan, is a day
of apyrexy or intermission. Such, for example,
was the opinion of Celsus, who treated of the
change of that form of disease into a quotidian.
The sentiments of Celsus on this subject were
> adopted by Hoffman, who mentions the forma-
tion of a quotidian out of a quartan, in such a
manner, however, he observes, that the pa-
roxysms do not commence every day at the
same hour.

Some physicians mention fourfold and six-
fold tertians and quartans; but these writers are
led by mere hypothesis, rather than observation,
to speak of fevers of this description : they have
seen paroxysms occuringin an irregular and dis-
orderly manner, and have endeavoured to arrange
them under certain types. But, in the first
place, fevers of this kind are not intermittents ;
or if they are, they pursue no regular course :
departing in a short time from the course in
which they began, they pursue a different one,

and that altogether broken and disorderly. But,
to conclude the matter at once, physicians of
long and extensive experience have scarcely ever
witnessed diseases of the kind.

Simple intermittents degenerate into other
compound forms of fever. They may be con-
verted, for example, as we shall presently see,
into continued fevers, still, however, preserving
so much of their original type as serves to dis-
tinguish them from all others. They may like-
wise be combined with other fevers, as with
those of a continued form. They have also been
known to be joined at times with certain other
morbid affections. But we will proceed first to
the consideration of simple intermittents, that
we may thence be the better enabled to com-
prehend the nature of such as are compound.

CHAP. II.

Of the various causes of Intermittent*, as laid down by
certain medical writers.

THE cause of intermittents, which acts and
lies dormant by turns, is extremely difficult to
be understood. Enquiries respecting it have ex-
ercised the ingenuity of physicians in every age,
and it has been supposed to reside in various parts
of the body. Many have considered it as lurk-
ing in the prima vice. The principal argument
in favour of this opinion is drawn from a
symptom constantly attendant on intermittents,
namely, a vomiting preceding the paroxysms.
As the febrile cause, therefore, acts first on the
stomach, it would seem to have its seat in that
organ. But nausea and vomiting usually precede
most kinds of acute diseases. Small-pox, pleu-
risy, and other similar diseases, do not originate
in the prima via, and yet they are for the most
part ushered in by a vomiting.*

* The translator, from his present view of the subject, is decidedly
of opinion, that the poison which produces bilious fever in all its
iorms, and also the variolous poison in cases of casual small-pox,

Others derive an argument no less feeble
from the effects of drinking cold water. Thus a
drink of cold water makes the disease more se-
vere, while a draught of warm water renders
the efforts to vomit much lighter. But in the
cold stage of the fever every part of the system
is contracted or shrunk up ; can it, therefore,
be inferred, that the first seeds of the disease
lurk in the primes vite, merely because a new or
additional contracting power, such for instance
as a draught of cold water, subverts the action
of the stomach ?

The insufficiency of these arguments appears
m a particular manner, from the uncertainly
that accompanies the use of emetic remedies.
If intermittents arose from the condition of the
prime? via, they might be removed by emetics
or purgatives alone. But every one must be
acquainted with the fact, that they do not yield to
remedies of this description, and that they are
not unfrequently even rendered more violent by
them. Besides, topical applications to the limbs,
and peruvian bark used by way of injection,

have their original seat in, and, therefore, make their first impres-
sions on, some part of the primes vice. This leads him to an unquali-
fied belief in the sympathetic doctrine of fever. These opinions he
hopes to lay before the public, at some future period, accompanied
by such facts and arguments as may contribute to their further esta-
blishment and more general reception.

have oftentimes been known to cure intermit-
tents : but these remedies do not operate by
evacuating the prima via.

Physicians have accused another part of the
body, which is no less innocent than the prima
via. The pancreas, for example, has been con-
sidered as the seat of the febrile cause, and this
opinion has been thought to derive support from
anatomical observations. That organ has been
found sometimes schirrous, and at other times
in a state of suppuration. But were not these
appearances the effect, rather than the cause of
the disease ? How many persons have laboured
under obstructions of the pancreas, without ex-
periencing any thing of intermitting fever ? We
will pass over that opinion, therefore, as a mere
conjecture. Nor are we inclined to set a higher
value on the sentiments of those, who consider
the fomes of the disease as lying hid in the reces-
ses of the mesentery, because the hypothesis is
not supported by either reason or experience.

With as little reason and justice has the dis-
ease been attributed to a deficiency of perspira-
tion. There are indeed some instances which
would seem to favour the belief, that intermit-
tents may arise from such a cause. It has been
observed, for exampie, that boys who had eaten
largely of summer fruit, have been seized with

intermittents on plunging themselves into a
stream of running water. A kind of febrile
paroxysm appears also to be excited by the use
of the cold bath. But it is no less certain that
perspiration may be checked without producing
any febrile affection. It appears also from the
circumstances of the cold of winter, which is so
unfavourable to perspiration, that persons when
warm are very often exposed to cold air without
experiencing any febrile commotion in conse-
quence of it.

From these causes which they considered as
uncertain, some physicians have retreated to
others less obvious to the senses. Many seem
to be fully convinced, that the origin of intermit-
tents is to be sought for in the action of the
nerves ; some, for instance, suppose it to be owing
to an inert or sluggish state of the nervous fluid,
while others attribute it to an irregular influx of
the same. They contend, in particular, that the
sudden invasion of the paroxysms can be de-
duced from no other source than the nerves.
Examples are brought forward, where an inter-
mittent appears evidently to have been produced
by the passions of the mind. For no other rea-
son, according to some, can peruvian bark prove
serviceable, but because it gives relief in hys-
terical or nervous affections.

It is indeed surprising that physicians should
have fancied causes of this kind, which are
so remote from the reach of the senses. I
confess that I oppose these hypotheses not with-
out difficulty. Who, I would ask, can prove,
that the nerves are alone affected in intermittents?
Suppose a person to be attacked by fever, in
consequence of a violent agitation of the nerves,
what then ? do not other affections also arise
from the same cause ? Besides, what peculiar
affinity to such a cause have cold, heat, profuse
sweating, apyrexy, and* a return of the pa-
roxysms at a stated hour ? Those who spend
their time in searching for these things in the
nerves, are idle theorists rather than practical
physicians intent on the cure of diseases.

CHAP. III.

Of other and more probable causes.

THOSE writers appear to have approached
nearer to the truth, at least to have more proba-
bility on their side, who have referred the cause
of intermittents to certain animal fluids. Among
these the first to be mentioned are the more an-
cient anthors, who have laid the blame especially
on the bile, namely on its redundancy or acri-
mony, qualities which show themselves more
particularly in the autumn, or, from various
causes, at other seasons.

If indeed any fluid can become too acrid, it
is the bile. This appears evident from the cir-
cumstances of its origin and formation, which,
however, do not seem to be very clearly under-
stood. This yellow excretion cannot be said to
be formed in the blood, and separated from
thence by certain strainers, because neither the
surface of the body, nor the internal parts are
tinged by it, when the liver is entirely indurated.
In the internal recesses of that viscus, therefore,

the officina or laboratory of the bile is neces-
sarily situated.

But it cannot be proved that the bile can be
formed either from fat, from lymph, or from
serum. Fat is not saponaceous, since it is no-
thing but mere oil ; lymph is white, coagulates
spontaneously in a short time, and does not form
an extract with spirit of wine ; the serum into
which all the humours are resolved, contains in
it nothing bilious, nor is any such quality attri-
buted to the urine.

It is more probable, therefore, that the im-
mediate matter of the bile resides in the red
portion of the blood, for the blood like the bile, is
saponaceous when rubbed on the hands ; it is
also resinous, in as much as it is inflammable
when dried, and forms a tincture with spirit of
wine ; finally, it is strongly disposed to putre-
faction, and, when in a putrid and dissolved state,
assumes a yellow colour : these latter circumstan-
ces are illustrated in cases of echymosis, and in
the putrefaction of blood under a gentle heat.

Now the blood returning from the intestines,
having left its more fluid part behind it, has a
tendency to a dissolved as well as to an alkales-
cent and putrid state. It stagnates in the me-
senteric veins, is exposed to a gentle heat, and is

tainted by the putrid halitus of the intestines.
It becomes therefore dissolved, and turns yellow
in the liver itself, in which it circulates but
slowly, and is at length separated or taken up by
the biliary tubes. Thus, as it is already inclining
to an acrid state, this acrimony can be the more
readily increased by the mixture of febrile mi-
asmata.

But if bile be the cause of intermitting fever,
it must necessarily have first acquired some pe-
culiar and unusual power : for it is oftentimes
in very great super-abundance without giving
rise to this disease. Nor indeed are those per-
sons who labour under jaundice more subject to
it, although the bile ought in such cases, if ever,
to prove troublesome and injurious ; for it then
stagnates in the liver, taints the blood and other
humours, disturbs the functions of the body,
and fails to perform its usual offices in the sto-
mach and intestines.

Influenced, no doubt, by these considera-
tions, some have supposed, that intermittents
are to be attributed to a certain putrid matter
contaminating all the humours of the body.
Hence arose their belief, that febrifuge medicines
possess properties strongly antiseptic ; such as
the peruvian bark, for example, which is a pow-
erful preventative of putrefaction. But it must

be acknowledged, that they who lay the blame
on putridity alone, carry the matter to an extra-
vagant and erroneous length. Putrid aliment
does not always produce intermitting fever :
besides, this disease oftentimes prevails in places
where not a vestige of putridity exists : there are
even certain remedies, such as testaceous sub-
stances, which promote putrefaction, and yet
possess febrifuge virtues.

But whether it be acrid bile, or some putrid
matter, that is the cause of intermitting fever,
it remains to be enquired whether it is confined
to some particular part, or is diffused throughout
the whole body. Some circumstances indeed
seem to prove, that the febrile cause is diffused
through the whole system ; when about to dis-
appear, it shows itself on the lips and around
the mouth ; for it produces pustules on these
parts, and leaves marks of its departure, when
it is gone. This position is further confirmed
by many other circumstances which sometimes
occur in certain cases of disease, and seem to
show that a poison is diffused throughout the
whole body.

But there are arguments not without weight,
which tend to prove, that the febrile cause is
principally confined to some particular organ, or,
at least, that there is some part to which its ac-

tion is more immediately directed and confined,
and which is, therefore a greater sufferer in con-
sequence of that action. This opinion is coun-
tenanced, as we shall presently observe, by
various phenomena attendant on intermittents.

From every view of the subject it would ap-
pear, that the part which more immediately
sustains the action of the febrile poison, is the
liver : for, in intermittents, the urine is tinged
with the same saffron and brick-dust colours, as
in hepatic affections. So great is the super-
abundance of bile in these diseases, that, on the
exhibition of an emetic, it seems to overflow,
and is often discharged of an oily nature and
very viscid consistence. So great is its accu-
mulation that it is necessary to have recourse to
vomits. Such a tendency has the system to ge-
nerate bile, that without procuring its evacua-
tion the disease cannot be removed.

Hence, as must necessarily be expected, the
countenance is for the most part suffused with
some degree of yellowness. In those who are
unskilfully treated and imperfectly cured, this
colour becomes so deep as to degenerate at length
into a true jaundice. Unless this affection be
removed, it is not to be expected that the dis-
ease will disappear ; at least, if it even should
terminate for a while, it will certainly have a

strong disposition to recur. Lastly, in those
who die of intermittents, the liver is always
more or less affected. It cannot, therefore, be
doubted but that in this complaint, that organ is
particularly and chiefly diseased, and constitutes
the principal seat of the fomes.

But in an investigation so extremely intri-
cate, it is not allowable to proceed any further.
It appears evidently that a certain matter is either
generated in the body, or is introduced into it
from without, and that this matter is diffused
throughout the whole of it, and proves noxious
to the liver in particular. But how is it concen-
trated in that viscus, and how does it acquire
strength I How does it show itself by making
as it were a sudden attack, and afterwards gradu-
ally abate, till it at length ceases to act ? Finally,
how does the fomes remain in its lurking-place ?
How does it contaminate the humours like a
ferment, and prove the cause of repeated pa-
roxysms ? These things cannot be ascertained,
till we shall have taken a survey of all the symp-
toms and effects of the fever.

CHAP. IV.

- *.

Of the remote causes.

IT is much easier to enumerate the remote
causes than to point out their mode of operation.
It is obvious to every one that intermittents are
the immediate offspring of changes in the wea-
ther ; yet it cannot be ascertained in what way
such changes contribute to the production
of these diseases rather than of others. We
only learn from observation, that by particular
states or conditions of the atmosphere, certain
motions or modes of action are excited in living
bodies : nor are these motions produced alike in
all kinds of animals : dogs, horses, and cattle are
not so liable to intermitting fevers, at least they
are but very seldom attacked by them.

The human system, on the other hand, is
very subject to these diseases. There is scarcely
any one who has not experienced something of
intermitting fever. This disease spares neither
childhood, manhood, nor old age. It prevails
in the spring, though more extensively in the

autumn, and also makes its appearance occasion-
ally during the severest cold of winter, and the
most intense heat of summer. But during these
latter seasons the occurrence of the disease is
much more rare. In general, a continuance of
intense cold or intense heat produces fewer dis-
eases, and those of a different aspect.

There are in the mean time certain years, in
which intermittents are rare during the spring,
and even during the autumn, the season in which
they more generally prevail. But at other times
they break forth sporadically, or epidemically,
and that in particular tracts of country rather
than in others. In such cases they begin and
terminate their ravages sooner or later, accord-
ing to the changes of the weather, or the nature
of the soil. When they commence early in the
season, we may look for an epidemic of consider-
able severity. These epidemics have been
known to continue with great violence and mor-
tality, even till some time in the winter. On
such occasions, however, those persons who had
been attacked by the disease during the autumn,
were the principal sufferers, while such as had
escaped till the commencement of cold weather
were seldom affected afterwards.

Intermittents prevail not only at certain sea-
sons of the year, but also in particular situ-

ations. Persons living in the vicinity of marshes
are particularly subject to them. They rage,
for example, in the northern parts of France.
The French troops suffered once the greatest
mortality from them, when they were encamped
along the coasts of Holland. On that occasion,
such was the nature and malignity of the fever r
that after having continued for a certain time it
scarcely admitted of a cure. Even the most ro-
bust systems and vigorous constitutions, when
much reduced by the violence of the disease,
carried the relicks of it with them through dif-
ferent climates.

This fever arose from marine exhalations,
which were, therefore, supposed to contain
something noxious derived from the waters of
the ocean. But other kinds of exhalations are
not less* hurtful. Near to the walls of a large
city stood a very extensive and deep pond of
water, which for forty years had served as a re-
ceptacle of all the filth from the houses and
streets. As long as these putrid matters remain-
ed covered with water, they were productive of
no mischief. But when they had so far accumu-
lated as to rise above the surface of the water, a
most malignant fever spread through the tract of
country adjoining the city. Where, previously
to this, only four hundred persons had died an-

nually, not less than two thousand were now
swept away,

Such was the peculiar power of thc?e exhala-
tions, that persons living near the pond, could
not preserve meat for the space of three hours ;
it usually began to putrefy almost immediately,
and all kitchen furniture became in a short time
covered with a kind of crust. Perhaps this fe-
ver was of a different kind : it was truly malig-
nant and produced various affections of the head,
a circumstance not so observable in the fevers
which prevail along the coasts of France. These
latter diseases more frequently terminate in
troublesome obstructions of the viscera.

Hence it appears, that in epidemic constitu-
tions of the atmosphere, there is something that
rises from the earth, and floats in the air, which
tends to the production of intermittents rather
than of other diseases. Of the nature and com-
*' position of this, it is extremely difficult to judge.
We learn, however, from observation, that a
similar cause may be generated in our own
systems, and that it sometimes originates from
the aliments we use ; yet these aliments cannot
be regarded as a certain cause of intermittents.
For, when any one, after an error in diet, is at-
tacked by a disease of this kind, he might have
been before pre-disposcd to it ; he might have

received a certain portion of miasma from the
reigning constitution of the season. Thus, in
camps, for instance, it is certain that if the pro-
visions be heavy and glutinous, like beans, or
austere and harsh, like unripe fruit, attacks of
intermitting fever are apt to be common through-
out the autumn*

Thus, then, it stands, with respect to these
and other occasional causes, such as sleeping in
humid situations, cold air, fatigue, passions of
the mind, such as anger and sorrow, long con-
tinued watching, and the use of heating medi-
cines. To these things, not as their proper,
but as their exciting causes, fevers are known
to succeed very frequently. The body being
already pre-disposed, has a disposition to take
on these diseases. Under such circumstances
the solids and fluids are, so to speak, thrown into
the flame of fever by a slight cause. It would,
indeed, be a secret, well worth possessing, to
know how to reduce the fever certainly to an in-
termitting type.

CHAP. V.

Of the febrile rigor, or cold stage of fever.

WHEN the febrile cause begins to act, a
sensation of coldness is immediately experi-
enced, a circumstance which occurs in other
acute diseases as well as in intermittents. But
in continued fevers the progress and violence
of the cold stage are widely different from what
they are in those of an intermitting type. There
are indeed some continued fevers of a malignant
character, which are ushered in by a severe and
dangerous chill. But in general it neither lasts
so long, nor is so troublesome to the sick. This
serves to apprize the practitioner of the nature
of the impending fever, and enables him to dis-
tinguish it from other diseases, even before the
hot stage is formed. For it may be laid down
as a general principle, that fevers which com-
mence with the greatest rigor, are to be classed
with those whose course is marked by stated
paroxysms.

The rigor or cold stage of fever can be attri-
buted to no other immediate source than an im-
pression or irritation made on the nerves by-
some hidden cause exciting them to action.
That this is the case appears from various ex-
amples that occur in practice. Thus, for in-
stance, the irritation of a biliary calculus on the
ductus cboledocus, sometimes excites the most
severe rigor throughout the whole body. The
same effect is oftentimes produced by a catheter
touching the bladder, and even by an enema
thrown into the rectum, when greatly pained by
a hemorrhoidal affection. A similar rigor arises
from certain visceral complaints, such as a
strangulation of the intestines, and also from
the formation of pus in any of the cavities of
the body. I once saw a soldier who, in conse-
quence of a large abscess of the liver, died of a
chilly fit which lasted two days. There is no
doubt, therefore, but the cold stage of intermit-
tents may be produced by a stimulus acting on
some part of the body.

The access of the chilly fit is usually pre-
ceded by various phenomena. These are, a
general lassitude and heaviness, a sense of anxi-
ety, a yawning and stretching, a paleness, and
sometimes a disposition to sleep ; then succeeds
the chilly fit, which puts on a variety of forms ;
sometimes, for instance, beginning at the feet,

at other times about the scapula;, and again in
the back, it runs through the whole body, in a
manner resembling small streams of water,
poured irregularly in every direction : hence
horripilations, shiverings, and repeated rigors,
as if cold water were dashed over the limbs.

The shiverings and rigors are oftentimes so
great as to produce a continued tremor ; the
hands, arms, and other members begin to shake;
the lower jaw in particular is seized with a very
quick and alternate tremulous motion, which
rises at times to such a pitch of violence and
force, that the teeth clash against each other with
a considerable noise, and are even said to be
sometimes broken. The motions being con-
vulsive and involuntary cannot be checked, not-
withstanding the greatest efforts of the patients
for that purpose. Agitated by such concussions,
the sick are unable either to sit or stand : they,
therefore, are forced to lie down, and to draw
themselves together in such a way that their
limbs may press on and support each other.

It frequently happens that all parts of the
body are not alike affected by the cold lit. I have
oftentimes seen the lower parts extremely cold,
and the upper ones parched with heat. Men-
tion is made of a patient who had one side cold
and the other hot. I myself had a person under

my care tn fever, who felt a coldness only in one
arm. There are other circumstances not less
rare, which variously affect the duration, strength,
and appearance of the cold stage. .But as these
do not very frequently occur, it is inadmissible
to dwell on them at present. Those things
which deviate from the common course of na-
ture, do not fall within the province of art.*
Besides, these anomalies are usually connected
with spurious fevers, not with true intermit-
tents,

Varieties also occur in the cold fit which pre-
cedes intermittents. Thus it varies in degree,
being sometimes light, sometimes moderate, and
at other times very severe. It attacks princi-
pally the extreme parts of the body, and but
rarely reaches, or is felt in, the internal parts. It
varies also according to the age and tempera-
ment of the subject. It is much more severe in
old and relaxed subjects, than in such as are
youthful and vigorous. Its duration is also dif-
ferent in different cases, as it sometimes lasts
two and sometimes three hours : I have known

* That isy stated rules cannot be laid down for anomalous occur-
rences. Under the pressure of such occurences, the practitioner
has nothing1 to depend on but his own sagacity and discernment.
Could rules be laid down, or predictions be formed respecting- them,

the events would cease to be anomalous and become regular

Trans.

it to be protracted even to the fourth and fifth
hour.

When the cold fit is longer than usual, this
circumstance is not to be considered as always
portending a more obstinate and severe pa-
roxysm. In general, indeed, the violence of the
hot stage of fever corresponds to that of the
cold:* but I have oftentimes observed, that a
tremor of but short duration was succeeded by
a most intensely severe paroxysm of many hours
continuance. On the other hand, I have been
surprized to find a long cold fit sometimes fol-
lowed by a short and light attack of fever.

The cold fit is not alike troublesome in all
the paroxysms of the same disease. Sometimes
it is scarcely felt by the patients, when the dis-
ease has run on to a considerable length : nor is
it indeed, at times, less inconsiderable even in
diseases of recent origin. There are some of
these which begin with a chill only at first, or
at most in two or three of the subsequent pa-

* Our author alludes here to the intensity, but not to the duration
of tiie hot stage. It is certainly true that a very severe cold fit, ac-
companied by a chattering of the teeth, and what is called, in common
language, a general shake, for the most part ushers in a high state of
febrile action. But this state is seldom of long continuance. A co-
piousperspiration soon comes on, and terminates in a short time tha
increased heat and arterial commotion Tra?is.

roxysms. After this the access of the paroxysms
is announced by a very slight chill, if by any at
all. But in true intermittents, unless they have
degenerated in consequence of the lapse of time,
the case is otherwise; these do not in general
deviate from the usual rule.

When the paroxysms are so protracted as
almost to run into each other, the cold fit is ge-
nerally less evident. Nevertheless, most per-
sons are admonished of the approach of the
fever by a slight degree of chilliness. Some-
times the coldness occurs only in the feet, and
at other times it is not attended to by the sick
at all ; while in other instances again, an oppo-
site state of things occurs. Thus, in fevers, as
in other movements or processes of nature, there
is no absolute stability. Some fevers do not
steadily pursue the course or type with which
they commenced, and others deviate from the
common laws of similar diseases.

It is not to be wondered at, therefore, if in
irregular intermittents, some unusual symptoms
should manifest themselves in place of thecoldfit.
I have accordingly seen some patients who com-
plained of a fixed pain in some part of the body,
resembling true rheumatism. There are others
again, who, on the approach of a paroxysm, are
seized with a sleepiness, Indeed so great is this

sleepiness, that it sometimes resembles real
coma. A certain female patient could scareely
be roused up ; and when she was roused, im-
mediately fell asleep again, and lay as if deprived
of sense : from hence it appears how easily the
mind may be affected. I once knew a woman
who, just before the paroxysm, became very lo-
quacious, nor was the approach of the disease
announced to the by-standers by any other
sign.

CHAP. VI.

Of the effects of the cold stage ef fever.

THE cold stage of fever produces many ef-
fects on the system at large. To speak first of
those that occur exteriorly, the arteries are con-
tracted. Nor can this be attributed to any other
cause than the action of the nerves on them.
Hence the pulse becomes small and frequent. It
begins, for instance, some little time before the
cold fit, to be depressed and to beat more slowly.
Afterwards it becomes more frequent and irre-
gular, particularly in persons advanced in years.
In such subjects it is often rendered tremulous
and uneven. In those that are more youthful,
it is not usually either so much depressed or so
irregular ; but of these things we will treat
hereafter.

From this contraction of the arteries arises a
paleness, which shows itself in the nails, the lips,
the countenance, and the other parts of the body
generally. To this even a livid colour is often-
times superadded. I once saw a woman whose

nose, during the cold stage of fever, was suf-
fused with something of an azure cast. At times
the skin is checkered with spots of a brownish
and bluish colour. The blood having passed
from the arteries, is collected and detained in the
fine net-work formed by the incipient branches
of the veins. This appears from injections of
the blood-vessels, by which small specks or pe-
techia are sometimes formed. But these phe-
nomena occur more rarely in the cold stage of
fever, though they often show themselves in
parts rendered livid by the action of external
cold. In this latter case, the blood stagnating
in the incipient venous branches, assumes a
blue or violet colour.

But a contracted state of the parietes of the
arteries is not of itself sufficient to produce a
stagnation of the blood. These vessels, even
when thus contracted, may possess great energy.
The blood must, necessarily, therefore, be thrown
into them with difficulty, during the cold stage
of fever. At this period that fluid is collected
in the larger veins, and the vena cava in particu-
lar is overcharged and uppressed by it. The
right auricle and ventricle of the heart are both
turgid at the same time, and may, therefore, be
considered as in a kind of press formed by their
own contents. Hence the contraction and dila-
tion of the ventricles are necessarily much con-

fined. From this source arises that convulsive
motion and palpitation of the heart, which some-
times occurs in the cold stage of fever. Finally,
to the same cause must we attribute that great
anxiety, and occasional syncope, experienced
by some persons at the commencement of a
paroxysm.

But wherefore is the blood collected in the
cavities of the heart ? Observation proves that
such a collection actually takes place. As to
the cause, it appears that the blood, being forced
by the violence of the cold fit from the external,
is driven to the internal parts of the body, and
is then by the various succussions or agitations
of the different parts directed towards the larger
veins. But not being able to pass immediately
through the lungs, it must necessarily be collect-
ed in considerable quantity in the pulmonary
artery, as well as in the right ventricle and au-
ricle of the heart.

Several causes co-operate in producing a stag-
nation of blood in the lungs. First, the texture
of the viscus itself presents a constant barrier to
the blood, as it issues from the heart : hence
that fluid is necessarily accumulated in the pul-
monary vessels. Secondly, the state of respira-
tion, during the cold stage of fever, contributes
to the same end' The acts of inspiration are

artiaJ and contracted : but when the vesicles
of the lungs are not properly expanded, the fluids
cannot find their way through them without dif-
ficulty, and must, therefore, be unavoidably ac-
cumulated in their vessels. It is not to be
wondered at, then, if patients sometimes expire
in the cold stage of fever, and if, after death,
their lungs are found distended with dark and
grumous blood.

Nor ought it to appear more strange, that,
seeing the viscera are thus turgid with blood,
the patients should suffer a burning heat within,
while the external parts of their bodies are freez-
ing with cold. When the hands and feet are
almost frozen in winter, the armpits and groins
generally retain the degree of heat that is natural
to them. But the same thing occurs in the cold
stage of fever. Indeed the surface of the body
being chilled at the commencement of the pa-
roxysm, the action of the viscera is thereby
rendered more intense, whence the heat in them
is necessarily augmented.

The degree of this internal heat may be dis-
covered in some measure from the intensity of
the thirst : for thirst is most troublesome when
the viscera are raging with heat. As in such a
state the fauces are drier than usual, we may pre-
sume the same thing to be the case with respect

to the surface of the aesophogus and stomach it-
self. But it is no less certain that thirst is
sometimes troublesome without any preternat-
ural increase of heat. It is excited in such
cases by acrid aliment, and by that saburra
which accumulates at times in the prima via ;
thus bile accumulates in these passages, the na-
ture of which is apt to be greatly vitiated in
febrile affections. I once saw a woman labouring
under a hepatic affection, who suffered great
thirst as often as the bile flowed in large quanti-
ties into her stomach.

That bile contributes to the production of
thirst, is further confirmed by the nausea and
vomiting to which patients are subject, dur-
ing the cold stage of fever. In the begin-
ning of paroxysms, in particular, large quanti-
ties of bile, sometimes tough and at other times
more liquid, are discharged by vomiting : that
fluid is even observed at times to be foetid. But
although this cause may be a powerful one,
others of no less moment may be combined
with it. The liver is affected, as we have al-
ready intimated: in the region of the stomach
spasms arise, which are to be attributed to the
stagnation of blood and the irritation thence
arising. Nor is it necessary for inverting the
motions of the prima via that the cause of in-
termitting fever be present. Pleurisy, nephri-

tis, and affections of the uterus are accompanied
by vomiting. The agitation of certain nerves
is sufficient for inverting the action of the sto-
mach.

This vomiting, or effort to vomit, is mark-
ed with some variety. It generally occurs at the
onset of fevers, and is violent and troublesome in
proportion to their severity. In vernal inter-
mittents it is less violent than in autumnal ones.
Even in the latter season it becomes milder after
a certain continuance of the disease. It finally
disappears altogether, and leaves nothing behind
it but the cold fit. From this subverted mo-
tion or evacuation of the stomach, no relief
whatever is to be expected. It is evidently a
morbid affection ; and notwithstanding the vast
quantities of offensive saburra thus spontane-
ously discharged, there always remains a resi-
duum behind that ought to be thrown off by an
emetic.

When by the force of the cold fit the action
of the nerves is thrown on the stomach, and
even the intestines themselves are constricted, it
is not surprizing that the fibres of all parts of
the system should be velicated and suffer some
degree of violence. Therefore it is, that on the
access or during the prevalence of the cold stage
of fever, various pains are so often felt through-

out the whole body. Sometimes the joints
ache, and the limbs are so painful, that they
seem to be affected by rheumatism. At other
times again, the pain is situated in some inter-
nal part. I have seen cases in which the intes-
tines themselves were tortured with pain. In
general, however, wandering pains and a kind
of painful pricking sensations are more frequent-
ly experienced throughout the whole or in cer-
tain parts of the skin.

But notwithstanding the pains excited at
times by the cold stage of fever, yet when that
affection is very severe, it renders sensation
much less acute. Under such circumstances,
if a slight wound be inflicted, no pain whatever
is experienced. There have even been patients
who were not sensible of the heat, when their
feet were moved close to the fire. For the same
reason purgatives do not act on the intestines if
exhibited during or just before the cold fit. The
stamina or constituent fibres and smaller vessels
of the parts are constricted by the action of the
cold ; the blood and vital principle cannot cir-
culate through their usual channels ; there is,
therefore, a deficiency of motion, which is the
principle of sensation, or, at least, that condi-
tion without which all things languish and
decay.

Hence we see what disorders may arise in
the functions of all parts of the body. The or-
gans of respiration are affected : the brain itself
is sometimes a sufferer : the secretions are dis-
turbed : perspiration is obstructed : the urine
becomes coloured, is thin, watery, and in small
quantity : as the renal tubes are constricted by
the action of the nerves, none but the more
fluid parts of the urine can pass off, for when the
motions in these small vessels are necessarily
diminished, the grosser particles can neither be
separated from the others, nor pass off through
such narrow channels : whence they must either
remain in their proper strainers, or be carried
elsewhere.

CHAP. VIL

Of the hot and sweating stages of fever.

AFTER the cold fit has continued for a
time, it begins to abate, and is succeeded by a
degree of heat which spreads gradually through-
out the extreme parts, and is marked by con-
siderable variety. It is more intense, for in-
stance, if the cold fit has been very severe. The
thirst still continues, with dryness of the mouth
and skin, pains in the joints, and not unfrequent-
ly great disquietude, tossing, and anxiety. The
whole body is nowT flushed, particularly the
countenance, the urine is of a red or flame co-
lour, &x.

To arrive at some knowledge of the cause
of this heat, let us attend to the circumstances
and mode of its occurrence in certain cases.
When a person is immersed in a cold bath, he
generally experiences soon afterwards a degree
of feverish heat. When the hands, already stiff
with cold, are rubbed with snow, a heat and red-
ness are excited in them, and a vapour or

smoke arises from them. When any one ex-
poses himself for a considerable time to a very
cold wind, or a freezing atmosphere, his face
begins at length to glow and be flushed. The
same thing takes place, accompanied also with
pain, in every part of the body which has experi-
enced an intense degree of cold.

Cold ought therefore to be considered as an
irritating cause:* in those parts long exposed
to its action a pungent stimulus remains, and
the small vessels being contracted in their dia-
meters, the fluids are accumulated in them and
made to stagnate. In this state of things the im-
pression of the cold either alone, or assisted in
its action by the irritation of the nerves, rouses

* Be the essence of cold what it may ; whether it consist sim-
ply in the absence of heat, or in the presence of an xtherial fluid of
equal subtility with the matter of heat, it is unquestionably, as our
author pronounces it, an irritating cause. In more fashionable me-
dical language, it is certainly a stimulus. This is a point as suscep-
tible of clear and satisfactory proof, as any one in the science of
physiology. We must necessarily bestow the name of stimulus on
whatever is capable of exciting in us motion cr sensation. But a
moment's reflection will convince us that cold is capable of producing
both. A current of cold air produces a blush and a glow of heat on
the face, by exciting action in the cutaneous arteries of the part. If
a person be in a deep sleep, a lump of ice or a ball of snow applied
to his skin, will awake him as instantaneously as the application of
hot water, or even of a burning coal. Innumerable other instances
of the stimulant power of cold might be adduced ; but it would be
equally improper and impracticable to dwell on the subject in the
limits of a note. Besides, the above instances are deemed suffici-
ent for my present purpose 7>ang.

the vital energy of the part : the blood being in-
cessantly urged forward with more violence than
usual, acts forcibly on the vessels that oppose
its passage : but from this constant motion and
distraction of the fibres, an increase of heat
must necessarily result.

There is no doubt but a similar cause oper-
ates in the case of intermitting fever. The blood
being accumulated by the violence of the cold
fit, stagnates in the cavities of the heart, in the
lungs, and in the mesenteric vessels. The con-
stant stimulus of this volume of blood excites
the vital energy, or the action of the nerves :
hence necessarily follows an increase in the mo-
tion of the arteries, and a corresponding in-
crease of heat. In the mean time, the greater
the contraction of the parts and the consequent
stagnation of the fluids, the greater in general
will be the degree of heat. Yet, at times, so
great has been the extent of this contraction,
that the vital power being oppressed and suffo-
cated, as it were, has been incapable of being
roused, and death has consequently ensued.

But we do not attribute so much to this
cause as to aliedge that the hot stage is produced
by it alone. There can be no doubt whatever
but fever arises from other causes besides a cold
fit. This is evident from those intermittents

which come on without a previous chill, at
least without a chill of any severity, and which
are notwithstanding at times extremely violent.
Besides, in continued fevers, in pleurisy, and
other similar affections, a cold fit generally in-
troduces the disease ; but afterwards there re-
mains an irritating cause or inflammation, on
which the succeeding hot stage and the whole
course of the fever depends. Lastly, I have
myself seen a periodical cold fit, which was not
succeeded by any appearance of febrile heat.

What seems to render it probable, that the
hot stage ought to be attributed to the preced-
ing cold one, is the effect of certain remedies.
It is observed, for example, that by these reme-
dies both the hot and cold stages of fever are
prevented. But if they have succeeded when
taken before the commencement of the cold fit,
who will venture to assert, that they did not ex-
ert their influence alike on the proper cause both
of the cold fit, and of the hot one ? That this
is indeed the case, innumerable circumstances
concur to prove, as we shall demonstrate when
treating of the cure of fevers.

The heat of the body in intermitting fever
rises higher than might perhaps on the first view
of the subject be imagined. It even surpasses
the heat that usually occurs in some very acute

fevers. It sometimes rises as high as the 39°
of Reaumur. Hence we see how great the heat
must be in those ardent fevers which oftentimes
partake of the nature of intermittents. It will be
the more intense, for instance, in proportion as
there is a greater quantity of blood accumulated
in the vena porta, the region of the heart, and
the lungs. It is in these parts, therefore, that
patients experience such a burning heat, for the
same reason that, in other diseases, other parts
suffer a similar heat, as the head, for example,
in phrenitiSy and the fauces in angina inflam-
matoria.

Sweat is a phenomenon of febrile heat. As
it flows, for the most part, copiously, when the
body is agitated by violent exercise, so it also
issues in abundance, when the action of the ar-
teries is somewhat increased. If, however, the
fever and heat be very violent, the pores of the
skin are not opened, but, on the other hand, the
texture of all parts of the body is constricted, or
thrown into a state of spasm. Under these cir-
cumstances a burning heat and dryness prevail
over the whole body, and must be expected to
continue till the fever abate : then the cutaneous
fibres and excretories being relaxed, the per-
spiration breaks forth on every side, and is pro-
moted by the degree of fever that remains, the

relaxation of the surface of the body, and the
fulness of the cutaneous vessels.

The reality of these causes of the flowing of
the sweat is obvious and well established. That
there is a relaxation induced, towards the close
of the fever, cannot be doubted. By the febrile
impulse the fibres are overstretched and weaken-
ed, for we know that flesh is rendered more ten-
der and soft by heat and motion. The fluids,
therefore, can pass more easily through the
pores, and that the more especially, as the cuta-
neous vessels are kept distended by the force of
the circulation being greater than natural. The
flowing of the matter of perspiration through the
pores of the skin, is much facilitated by the
change that occurs in the crasis of the blood.
It is evident that that fluid is in some measure
dissolved in those persons who have suffered an
attack of fever : for such subjects become pale,
and, as it were, bloodless, and are yet subject
at times to hemorrhages : they even fall occasion-
ally into a scorbutic diathesis in consequence of
the vitiation of the blood.

Hence it appears that great variety may oc-
cur with respect to the sweating stage of fever.
In some patients, for instance, the sweat begins
to flow at the very commencement of the hot
stage : in others it is more tardy, not appearing

till a little after the body has become hot ; while
in others again it breaks out at a still later period :
it continues also to flow for a longer or shorter
time, and is sometimes profuse and at other
times in smaller quantity. These circumstances
are necessarily varied according to the cause of
the disease, the affections of the viscera, the va-
rieties that occur in the hot and cold stages, and
the temperament of the patient. Hence the
perspiration is at times unusually copious. I
once saw a person labouring under intermitting
fever, who experienced such a deluge of sweat
six times a day, that he was forced to change
his linen twice or three times every hour.

As the action of the hot stage on the organs
of perspiration is various, the same thing is true
with regard to the other organs of secretion ;
hence the urine assumes a red colour. This
fluid is thin during the prevalence of the cold
stage ; foi\ during that period, all the secreting
tubes being constricted or affected by a spasm,
and the motion of the fluids being languid, none
but the finer particles can pass through the se-
cretory vessels of the kidneys, while the grosser
ones remain mixed with the other humours.
But as the febrile action increases, the urine ac-
quires aflame colour; this colour arises from
bilious and oily particles being mixed and incor-
porated as it were with each other, and is mark-

ed with some variety of appearance ; that is, it
is sometimes deeper and sometimes lighter.
The colour of the urine is rendered deeper by
profuse sweating, because, in such a case, the
more subtile and limpid fluids pass off by the
pores of the skin, whence the urine is necessarily
robbed of them, and its redness becomes con-
sequently more concentrated and more deep.
Thus, when any one has used severe exercise
and perspired plentifully, the urine which he
discharges is hot and in small quantity, but is at
the same time frothy and has its surface covered
with a thin pellicle : in this case, when the force
of the paroxysm has abated, a two-fold sediment
is deposited, namely, a lateritious one, and a
smooth white one. The first of these, of which
we will treat elsewhere, is a symptom of dis-
ease, but the other a sign of solution or return-
ing health. Respecting these sediments the
ancients have written much, but I would not
vouch for the authenticity of their observations
and opinions. By modern writers the subject
appears to have been too much neglected.

At the very commencement of intermittents,
Galen was in the habit of predicting their termi-
nation from the appearances of the urine. Ac-
cording to him, the solution is to be looked for
after the fourth paroxysm, if the urine be red or
yellowish, and emit a smell ; after the seventh,

if the urine be only red, and after the third, if on
the first day of the disease a smooth and even
sediment be deposited. This subsidence is in-
deed of great moment, particularly in quartan
fevers, but, as we will elsewhere demonstrate, is
subject to great variety.

CHAP. VIII.

Of the state of Apyrexy, or freedom from fever,
which succeeds each paroxysm.

AFTER the sweating stage an apyrexy or
freedom from fever succeeds, and all things seem
to be restored to their natural state. But the
course or progress of this period during which
fever lies dormant is various, and many things
occur in it worthy of notice. As far as our
senses are capable of investigating the subject,
the intervals might indeed be considered as per-
fectly exempt from disease (for they are scarce-
ly marked by the shadow of a complaint :) but
it is hardly possible that so very rapid a transi-
tion could be made from health to disease, and
from disease to health. Hence Galen expresses
some doubts respecting a state of perfect apy-
rexy. He could not be induced to believe, that
the intermediate days were perfectly free from
fever.

With many persons the nights preceding the
paroxysms are restless and uneasy, and, if the

matter be carefully examined, it is evident that
some slight symptoms of disease remain during
the days of intermission : at least it may be laid
down as an established point, that it is during
the middle portion only of the intervals between
the paroxysms, that the system can be free from
all preternatural action. Even during that pe-
riod the tranquillity and health of the system can-
not be complete, because the fomes of the dis-
ease still remains, and must, from one paroxysm
till another, act the part of a preternatural stimu-
lus. Besides, health cannot be considered as
sound, while disease still remains pictured in
the countenance, while the urine and faeces put
on unnatural appearances, and while the appe-
tite is for the most part defective, and the di-
gestion imperfect.

As the stated hour of the paroxysms ap-
proaches, a commotion or disordered action
more or less perceptible is necessarily excited in
the system. The access of these paroxysms
generally falls on the same hour of the day. Not
unfrequently, however, their order is interrupt-
ed. They sometimes anticipate, for example,
the usual time of their invasion, so as to occur
before it, sometimes by very short and at other
times by longer spaces. This is an evidence
that the disease is acquiring strength, and hasten-
ing on to a continued form. But if, on the other

hand, the fever makes its attack at a later hour,
this is a proof that it is losing strength. Each
postponing paroxysm is milder and shorter,
whence a hope may be derived that the disease
is inclining to a speedy and favourable termi-
nation.

But there are other circumstances besides
the time of their invasion or commencement, in
which the paroxysms differ from each other in
different fevers. The intervals between them,
for instance, are sometimes longer and some-
times shorter. Hence tertians are divided into
two kinds, the legitimate or true, and the bastard
or spurious. The paroxysms of the legitimate
kind are said to last twelve hours, but those of
the spurious somewhere about eighteen. A s to
the first, namely, the legitimate or common ter-
tian, its paroxysms are scarcely ever observed
to continue so long as twelve hours, at least
such a thing has not occurred to me during a
practice of forty years continuance. We learn
from daily experience, that the paroxysms are
limited to five, six, seven, or eight hours. From
this rule, however, we must sometimes except
the first few fits of the disease, which, in certain
constitutions, are protracted occasionally to a
greater length.

It is supposed that the course of the pa-
roxysms has many things in common with con-
tinued fevers. Some are of opinion, for instance,
that, as certain continued fevers terminate in
seven days, so a tertian fever is to be limited to
seven rounds or paroxysms. But it ought to be
remarked, that a continued fever rages both day
and night for the space of seven days, whereas,
an intermittent continues only from five to eight
hours out of twenty-four. Besides, there are
some continued fevers, which terminate on the
eleventh, fourteenth, or twenty-first day ; on what
principle, then, can these be referred to any de-
scription of intermitting fever? can they be refer-
red, for instance, to the quartan which is of longer
duration than the tertian ? Let us suppose that the
termination of this disease falls on the sixtieth
day, a position which is altogether doubtful :
there will occur during this period fifteen ac-
cessions or fits, each one of six or eight hours
duration : but, on the other hand, the continued
fevers run on throughout the whole of the four-
teen or twenty days without any intermission.

If there be any point of similitude between
intermittents and continued fevers, it lies ex-
clusively in the circumstance of their remission
or abatement. They both, for instance, are
marked by exacerbations and remissions occur-

ring at stated times. But the fever is perma-
nent, and even its remission extremely short,
and at times scarcely perceptible ; while, on the
other hand, the intermittent ceases or appears to
cease entirely for one or two days. But there
can be no real affinity between fevers that con-
tinue without intermission for a long space of
time, and those which alternately appear and
disappear at stated times.

CHAP. IX.

Of the cause of the disappearance and recurrence of
the fever at stated periods.*

WHENCE is this alternate disappearance
and regular return of the fever at stated periods ?
If indeed it be practicable to fathom this subject

* Tie physician who undertakes to account for the periodical
recurrence and termination of the paroxysms of an intermittent, may
be truly said to « attempt the bow of Ulyssis" As there are few-
subjects more curious and interesting", so there are none more dif-
ficult, in the science of medicine. Although our author fails entire-
ly in his attempt to explain it, I am unable to direct the reader to
any writer who has been more successful. The matter is as much
an arcanum naturce now, as it was in the days of the father of physic.
Nor does it seem at all proba )le that the thick veil which has hitherto
concealed it will be shortly removed. This veil is of too strong a
texture, and is too firmly secured in its place, to yield to the lili-
putian efforts of hypothesis. It resists with equal ease the torpor,
and the accumulated excitability of Darwin, and the debility, spasm,
and consequent re-action ot Cullen. Although the rapidly progres-
sive state o~ physical science convinces me that it will yet be removed,
I am equally confident that its removal must be reserved for a much
more enlightened period than the present. Without the least ex-
pectation of shedding any additional light on the subject, I will sub-

Intermitting fevei* arises from a local affection, produced by an
aeriform poison which gains admission by the mouth. This affec-

at all, the solution of the question nuist be
sought for in the phenomena and analogies of
the febrile cause, and in the alternate movements
or states of action of various parts of the body,
and of various affections- We must first, there-
fore, enquire into the varied march or progress
of the febrile cause. ...Why it breaks out or ma-
nifests itself at one time and lies dormant at ano-
ther, a subject ift itself both intricate and
obscure.

Of the nature of this cause we are entirely
ignorant : this only we know, that it possesses

tion has its seat in some part of the primce vice, most probably the
stomach. After it has existed for a certair length of time, it brings
the whole system into sympathy, thereby producing a paroxysm of
fever. But to explain why this paroxysm terminates within a given
time, and returns again at a stated period, " hie labor, hoc opus est."
When we have arrived at this point, we may be truly said to have
reached the " ultima thult" of the present state of pathology.

In the mean time, I have little doubt but the regular returns of
the paroxysms of an intermittent at the same hour of the day, are in-
timately connected with solar influence. The disposition of the suo-
jects, when cured, to relapse at weekly periods, bespeaks also the
subjection of this disease to lunar influence. It appears highly pro-
bable, then, that the two great heavenly luminaries, the regents of
the day and of the night, which exercise such an extensive and well
known agency over the ocean, the atmosphere, and the vegetable
kingdom, will be yet found to act a very important if not a principal
part, in producing the periodical recurrences and other phenomena
of intermitting fever. It must be recollected that the human s\stem
when debilitated by disease, is very readily and greatly afl'ected by
causes, which make no sensible impression on it when in a state
of health Trans.

a power of stimulating and inflaming, or, at least,
exciting heat ; that it attacks and greatly op-
presses the vital principle, until being itself at
length subdued by the increased motion and
heat which it excites, it seems to act as a remedy
against itself. Here the circumstances and
mode of action are somewhat similar to those
that occur in a case of surfeit, where the sto-
mach is oppressed by a super-abundance of
food, and where a fever which is forthwith excited
by this oppression, subdues, concocts and throws
off from the system all hurtful matters that had
been mixed with the blood. But the fever ex-
cited by a surfeit differs from an intermitting
fever in this, that the former perfectly cures it-
self, and does not recur again, unless re-produced
by a fresh error in diet.

The seeds of intermitting fever still remain
in the system after the paroxysms, and, there-
fore, when at stated times they break out and
show themselves in fresh paroxysms, this must
arise either from their power increasing and dif-
fusing itself like a ferment in every direction,
or from a collection and concentration in some
one part, of that which was before dispersed
throughout the body. But if these seeds of
fever exert their powers in consequence of their
energies being increased or concentrated, how
is it that they remain or appear to remain wholly

inactive during the time they are acquiring
strength by such increase or concentration ? In
this respect, the power of the febrile cause to
excite inflammation or heat resembles the in-
flammable property of gun-powder, which, when
left to itself is altogether inert, but explodes as
soon as it is brought into contact w7ith fire.

When, therefore, the seeds of intermitting
fever lie dead as it were during the days of inter-
mission, they want a cause to excite them to ac-
tion. But to determine what this cause is, is a
point of no small difficulty. Many things in-
deed seem suited to excite the fever ; but these
cannot be subjected or made subservient to any
particular type. It follows, therefore, that, at
stated periods, the febrile cause must break out
of itself; and these periods are separated from
each other by longer or shorter intervals, accord-
ing as the cause derives strength from extrane-
ous and surrounding circumstances.

But what seems truly surprising is, that the
febrile cause, while still lurking in the system,
may be prevented from exciting real fever,
though not from producing other morbid affec-
tions. By the exhibition of certain remedies,
for instance, the paroxysms may be completely
suppressed, and yet the whole system continues
to be disordered. Thus, there are sick persons

in whom the suspension of fever is succeeded
by a sense of general heaviness and debility, a
swelling of the abdomen, and a loss of appetite,
symptoms not to have been expected, had the
paroxysms continued. Sometimes the patient
is relieved from all these complaints by a renewal
of the paroxysms, so that his cure seems to arise
from a return of the febrile affection.

At other times, what is still more surprising,
after all the symptoms have disappeared, the fe-
brile fomes still remains behind perfectly harm-
less. It acquires strength in secret, or rather
lies hid like embers concealed by ashes. In this
state of things, if any error in diet be committed,
if the body be exposed to cold or humidity, or
if the functions be deranged in any other way,
then the fever, which had lain dormant for a
month or longer, returns and rages with as much
violence as at first.

Nor can the disease be said to originate from
these causes : for there is nothing in them cal-
culated to produce intermitting fever rather than
any other affection. The original disease is re-
newed, therefore, only because no other form of
fever can then occur. If the original complaint
was a tertian or quartan, that which breaks out
afresh, as here stated, assumes the very same
type. The same cause, therefore, still remains,

without having sustained the slightest change in
its nature.

This same constancy or immutability is ob-
served to exist even in cases of re-duplication.
When these happen in a tertian, the disease be-
comes a double tertian ; and when in a quartan,
a double quartan is the result : the paroxysms
still pursue the same order, and correspond to
each other every third or fourth day. Even in
cases of anticipation, intermittents not unfre-
quently preserve a certain order ; thus, at times,
the paroxysms precede the stated hour of acces-
sion every day by an equal period.* Lastly,
in their decline and disappearance, these fevers
do not depart from this order. In a double ter-
tian, for instance, one of the diseases sometimes
terminates, while the other still remains with all
its usual characters. The same thing is observ-
ed in double and even triple quartans.

It must not, however, be supposed that the
nature and form of fevers are so uniform and
immutable as not to admit of a tertian being
changed into a quartan, or (a circumstance
which more rarely occurs) a quartan into a ter-

* This is a point of which the practitioner should never lose sight,
as it is calculated to serve him very materially in his attempts to
break the course of an irregular disease.... 1 'rar.s.

tian or a quotidian. Hence it appears, that each
of these forms of fever arises from nearly the
same cause, or, at least, that the}' are closely
allied to each other. But the tertian is apt to
be the most irregular; it oftentimes undergoes
such changes, that it retains nothing of its pri-
mary type, and can therefore scarcely be distin-
guished. Perhaps the most remarkable of these
changes is, when it assumes the form of a hectic
fever, and clothes itself in symptoms totally dif-
ferent from those that are common to it.

Intermittents when somewhat on the decline
are extinguished at times by a single blow as it
were, nor can we discover how the causes that
thus destroy them possess such an influence over
them. They are removed by great and sudden
emotions of the mind or body, as terror, for in-
stance, has been known to cure a quartan ague.
The same thing has been effected by anger, in-
tense heat, violent exercise, and great com-
motion of the internal parts of the system.
But, what is less to be wondered at, these same
causes are capable of rousing into action the
hidden and dormant fomes of intermittents.
Thus the mere appearance of an unusual object,
the sight of a dormouse, for instance, has been
sometimes known to renew the disease with the
utmost violence.

What is perhaps more singular still, inter-
mittent are removed by various remedies,
which are even sometimes opposite to each other.
Whatever these remedies may be, the diseases
are cured by them on nearly the same principle
on which poisons are counteracted by their anti-
dotes. At other times the febrile poison leaves
the system spontaneously, as it were, without
any previous commotion whatever. But, what
is more to our present purpose, after the fever
itself has ceased, certain vestiges of it frequently
remain behind. Thus there are morbid affections
which show themselves about the same time
of day at which the paroxysms usually occured.
These affections consist in a heaviness or pain in
the head or body, or in a certain disagreeable
sensation wrhich affects the whole system. If
certain authors are to be credited, an intermitting
fever, when it recurs even after a long suspen-
sion, or interval of health, usually attacks the
patient at the same time or about the same hour
of the day, at which its paroxysms had formerly
occurred.

CHAP. X.

Whether or not any thing occurs in other morbid affec-
tions, or in the action of the various parts of the
body, to enable us to discover the cause of febrile
periods*

LET us now return to the question formerly
proposed, namely, whether or not any thing
arises out of the foregoing considerations, that
can enable us to explain why the cause of inter-
mittents acts and lies dormant in the system al-
ternately? Here it must be acknwledged, that
the preceding history of the phenomena of inter-
mittents, instead of illustrating the matter, tends
to render the laws and principles by which this
cause is governed, more uncertain and intricate.
Let us see, therefore, whether or not any thing
can be deduced from other affections calculated
to shed light on this obscure subject. In these,
many things occur which may be well applied to
intermitting fever : even in those affections
which are dissimilar to each other, certain phe-
nomena take place, from which we may dis-
cover, or at least form some idea respecting,

the causes of alternate motions or states of ac-
tion in the system-
Some writers, in their enquiries after the
cause of febrile periods, have considered the dif-
ferent parts of the bodies of animals so construct-
ed and disposed, as to be capable of being
brought into subjection to certain arbitrary
laws ; thus, for instance, any person may, at
pleasure, say they, so regulate the alvine evacu-
ations, as to make them occur at a stated time ;
the appetite for food may be so regulated as to
be felt only at certain hours; sleep may also be
circumscribed within given limits, for we can
accustom ourselves to awake regularly at the
same hour in the morning : But what are we to
conclude from hence ? Surely it cannot be said
that in intermitting fever the different parts of the
system become by habit accustomed to alternate
rest and motion ; because from the very begin-
ning of the disease, they assume that state of
action which they are to continue till its close.

There are certain motions or states of action
both natural and preternatural, which approach
nearer to the movements of intermitting fever.
The eatamenia, ibr instance, appear only at
stated times ; the same thing happens not mi-
frequently in hemorrhoidal affectioas, In both
these cases we can attribute the phenomena to

no other cause, than the volume of blood, which,
increasing for a time, makes its way at length
through the outlets of the uterus, or through the
patulous mouths of the hemorrhoidal vessels.
To a similar cause may we attribute the efflux
of bile, saliva, perspirable matter, and sweat,
which sometimes observes stated periods. The
same thing may be said respecting the urine,
which, at times, is discharged more copiously
than usual, at stated periods.

Somewhat similar is the disposition of cer-
tain tumors, which are accustomed to pour forth
periodically, a quantity of blood. These tumors,
when carefully examined, exhibit veins changed
by a great dilatation into large canals : the
blood being poured from the arterial capillaries
into these canals, increases to a considerable
volume, and at stated times bursts the barriers
opposed to it, and escapes. I have seen occasi-
onally another example in various tumors when
cut through the middle : from these, a periodi-
cal hemorrhagy has taken place, on account of a
collection of blood in some cavity.

There are other periodical affections which
cannot be deduced from the same cause: such
are different forms of hemicrania, and pains
sometimes extremely acute, which appear and
disappear alternately, and as it were in a certain

routine or regular order. There are many other
movements or states of action that occur in the
animal machine, which may be likened in some
measure to the ebbing and flowing of the sea.
Kven continued fevers themselves are marked by
remissions and exacerbations. They are gene-
rally worse at night and better in the morning.

But from what cause can these things be de-
duced with more probability, than from some
kind of matter, the quantity of which is increas-
ed or diminished, or else which becomes alter-
nately more acrid and more mild in its qualities ?
May not an argument in favour of this opinion
be drawn from continued fevers that terminate
by an imperfect crisis ? A large quantity of
morbific matter is expelled, and therefore tran-
quillity is restored to the system for some time :
but the morbific matter still remaining behind, is
collected afresh, and recovers strength, and
hence a relapse is apt to occur.

Something similar appears in gout and epi-
lepsy. In gout, in particular, there can be no
doubt but there is present a certain morbific
matter which gives rise to the disease: for a
long time this matter circulates through the sys-
tem without producing either commotion or in-
jury : it is collected or accumulated, at last, in
certain places fit for its reception : but when i

has become thus collected, and is by any means
set in motion, an attack of gout is the immedi-
ate consequence.

As to epilepsy, that disease also appears at
times to originate from a collection of morbid
matter. When, for instance, it arises from a
particular spot that has been bruised or wound-
ed, does there not appear to be in that spot a
certain collection of particles by which the nerves
are at length irritated and roused to morbid ac-
tion ? and is not this much more evidently the
case when the cause of the disease consists in a
retropulsion of miasmata ? for if the pores of the
skin remain open and these miasmata be expelled
through them, the disease is brought to a termi-
nation, and a collection of the miasmata thus
prevented.

These remarks are applicable, at least in
part, to intermitting fever, in as much as there
are many circumstances which are common to it
and the diseases just mentioned. Thus the
cause of gout, like that of intermitting fever, can
lie dormant for a given space of time ; it is
sometimes roused suddenly into action, either
spontaneously as it were, by passions of the
mind, or by errors in diet ; it produces at times
a fever not unlike intermitting fever ; it may be
repelled into various parts of the body, and there

give rise to various diseased affections ; it is at
length sufadttcd or rendered inactive by pain and
length of time ; besides all these points of
likeness between intermitting fever and gout,
when the accumulated matter of the latter dis-
ease is dissipated and ceases to act, the fomes
still remains behind in the system, perhaps un-
changed, and towards autumn, but oftenerin the
spring, comes again into action and produces the
complaint anew.

Notwithstanding the dissimilitude of epi-
lepsy and intermitting fever, these diseases ex-
hibit certain characteristics which are common
to both. Epilepsy is sudden and unexpected
in its attack ; it irritates the nerves and draws
them into consent or sympathetic and synchro-
nous action ; it is sometimes regularly perio-
dical ; it is excited by passions of the mind and
errors in diet, and its cause is subdued or ex-
pelled, by internal and external motions or
states of action ; still, however, there remains
behind a fomes by which similar attacks may be
afterwards produced.

An attack of hysteria bears also some de-
gree of resemblance to an attack of intermitting
fever. That affection arises from a turges-
cence of the uterus, and is sometimes sudden

in its occurence, like epilepsy, from which it
does not greatly differ ; it disorders the sto-
mach, produces coldness, and excites other
troublesome commotions in the system. In
this case the nerves are irritated and continue
under this irritation till the menstrual evacua-
tion takes place, and the congestion of blood is
removed.

If, then, it be allowable to indulge a conjec-
ture on the subject, it would appear from the
the foregoing considerations, first, That there
exists in intermitting fever a certain noxious or
morbific matter generated within the body or in-
troduced from without, capable, as we have al-
ready said, of being diffused throughout the
whole system. Secondly, That this matter
is particularly hurtful to the liver, that it is
accumulated in, and exerts its action on that
viscus. Thirdly, That after this matter has
attained to a certain state of accumulation,
and acquired a certain degree of power, it ir-
ritates the texture and nerves of the liver, like
a foreign stimulus, retards the progress of the
blood, and renders that fluid acrimonious and
vitiated in its qualities. Fourthly, That this
matter by its powerful action on the nerves
throws the whole body into commotion, and is
at length, by the fever that ensues, expelled

and dissipated as it were both from the place
primarily affected, and from every other part
of the system. Fifthly, and lastly, That a
fomes still remains behind, which, gaining
strength by degrees, may produce a recurrence
of the same commotions.

CHAP. XL

Of the diversified action of the febrile cause.

BUT whatever conclusions may be formed
relative to the preceding points of discussion,
it at least appears obvious what a great variety-
may occur in fevers, or what various appear-
ances these diseases may assume. The febrile
poison may put on forms altogether different
from each other. So greatly at times do the fe-
vers which it induces appear to differ from one
another, that some writers have considered them
as belonging to different species : yet the ac-
tual difference between them is not so great :
diseases arising from the same source may pur-
sue dissimilar courses, or be accompanied by
different symptoms.

Some authors contend that they can prove by
many arguments, that vernal and autumnal in-
termittents are not of the same kind. Vernal

intermittcnts, say they, are of salutary effect; they
require little or no medical aid ; they usually ter-
minate with the seventh paroxysm ; they are not
accompanied by malignant symptoms ; they
are not characterized by such a degree of nausea,
vomiting, and burning heat ; the urine in them
is not so high coloured, nor does it deposit such
a lateritious sediment; the sweats attending
them being less copious, the strength of the pa-
tients is not so much exhausted ; vernal inter-
mi ttents do not commence as quartans, nor do
the tertians assume that form ; finally, autum-
nal intermittcnts are eradicated by vernal ones,
and vernal ones by those of autumn.

But arguments of this kind are altogether in-
conclusive. What proves at once that these
diseases are in reality of the same nature, is,
that during the course of the same epidemic
prevalence, they do not differ from each other
in appearance. If, for instance, an epidemic
intermittent occur in the spring, it abates or en-
tirely disappears in the course of the summer,
but, on the approach of autumn, oftentimes
breaks out again, is attended with the very same
symptoms, and assumes the same character.

Nor, indeed, are vernal and autumnal inter-
mittcnts more dissimilar to each other, even
when they are not epidemic. Both their symp-

toms and their type are precisely the same.
Their only difference consists in this, that the
vernal intermittents happen at a time best cal-
culated to effect their solution or cure. At
that season our bodies are renovated as it were,
perspiration is free and active, and hence it is
that those autumnal intermittents which run on
till spring usually terminate then.

It appears then that there is only more or less
difference in the effects of the febrile poison, its
nature being always the same. The most strik-
ing difference in its effects is that which forms
the different types of disease, such as tertians,
quartans, &x. These affections, however dif-
ferent from each other in appearance, are the
same in their nature, for they are sometimes
changed into each other. Every experienced
practitioner must have seen tertians changed
into quartans, and quartans into tertians : be-
sides, the same symptoms are common to both
forms of the disease : in both, the cold, the hot,
and the sweating stages succeed each other in
the same order : if any difference whatever oc-
cur in the causes of these affections, it consits in
their being more or less powerful : but how it
happens that the poison comes into action and
excites disease every third or every fourth day,
is a question that cannot be determined.

There are notwithstanding, in the opinion
of many persons, certain points in which ter-
tians and quartans differ from each other. If
we may give credit to certain writers, it is even
practicable to foresee from its very commence-
ment what type the disease will assume. Ter-
tians, for instance, are marked by a shivering
and a great coldness, but quartans most frequent-
ly by a chilliness or shivering alone: if a real
coldness does occur in quartans, it is not pun-
gent and pricking, but a more dull sensation,
as if the bones were bruised; the cold stage is
also, for the most part, of longer duration, par-
ticularly in persons advanced in years, to whom,
as we have already remarked, it proves some-
what dangerous.

If we can give credit to certain observations
that have been made, the pulse exhibits a differ-
ence no less striking in these two forms of dis-
ease. Thus, at the accession of tertians it is
said not to be much slower than natural, but is
considerably more so at the commencement of
quartans. In the latter form of disease, as in
old age, it is slow and hard; in many cases tre-
mulous, obscure, and very unequal ; after hav-
ing been quick, frequent and small, the pulsa-
tions oftentimes become stronger, and are
marked by considerable intermissions. In con-

firmation of what we have here advanced, Galen
has remarked, that the pulse seemed confined,
almost as much as in the case of an ossified
artery.

The hot stage in quartans is not so intense
and burning as in tertians. The flowing of the
sweat is in some cases less and in others more
profuse. The urine also assumes different ap-
pearances in different cases: according to Galen,
it is crude and pale in the beginning, but be-
comes higher coloured as the disease advances:
it then deposits a kind of settling which is white,
not red or lateritious. Some physicians, how-
ever, have witnessed phenomena altogether dif-
ferent from these. They have seen the urine
saturated or turbid at the commencement of the
paroxysm, and afterwards depositing a laudable
sediment. On the days of intermission they
have observed that fluid to be more thin and lim-
pid ; but, what is of greater moment, it became
turbid and black previously to the solution and
termination of the disease.

There is no doubt, indeed, but these pheno-
mena have been observed; but they must not
be considered as constant and uniform. As far
as my experience and observation have gone,
the difference between tertians and quartans

is in general not so great. The appetite is in-
deed, for the most part, stronger and better in
quartans than in tertians ; the cold lit also lasts
longer ; but the shivering and agitation of the
limbs are not so great ; the pulse is more de-
pressed and unequal ; the febrile heat is less in-
tense; the paroxysms are shorter ; the sweats
are more protracted, but less profuse, and occur
not unfrequently at night even during the pe-
riods of intermission ; the urine is of a lighter
colour, and if the intermission happen to be
longer than usual, becomes oftentimes thinner
and more limpid during the continuance of it ;
not unfrequently however, it is observed to con-
tain a latcritious sediment.

A greater difference exists between tertians
and quartans with respect to their course, solu-
tion, and cure. Quartans are of the longest
duration, running on for a year and sometimes
longer. When they continue for a greater
length of time, they are cured with more diffi-
culty. They are said to have oftentimes yielded
to the hemorrhoidal flux. But on these several
points enough and even more than enough has
been already advanced. We will intentionally
pass over other circumstances which ancient
writers mention as peculiar to these fevers,
but which, though they may be true, are not

perfectly conformable to our own experience.
It is of most consequence to have a thorough
knowledge of those circumstances that are most
frequently met with in practice ; the more
rare occurrences are not so much the objects
of art.

CHAP. XII.

Of febrile affections ivhich, though different from in-
termittents, assume their external appearance.

INTERMITTING fevers, the course and
nature of which we have endeavoured to define,
are, in general, very easily distinguished from
other diseases. But we meet occasionally with
certain febrile affections, which, though altoge-
ther different from intermittents, assume not-
withstanding their external appearance and cha-
racter, and fallaciously seem to be of the same
species. Febrile affections of this description
are numerous, and arise from various causes.
It becomes an object of consequence, therefore,
to point out the mode of distinguishing them
from genuine intermittents.

In certain catarrhal affections, the fever lies
dormant or intermits during the day, and comes
on at the approach of night, being preceded by
a chilly fit. After various pleuritic affections,
when the patients have been tolerably well

throughout the day, paroxysms occur towards
evening, which give us cause to suspect the
existence of an abscess or some other relic of
the disease. In those fevers to which lying-in
women are subject, something like an intermis-
sion takes place. Even in continued fevers, the
system is oftentimes in some measure cool and
tranquil in the morning, but night brings along
with it a paroxysm sometimes of greater and at
other times of less severity, and which for the
most part is not preceded by a cold fit. These
fevers disappear in general by degrees, and that
without the assistance of febrifuge medicines.
Finally, hysterical affections are marked at times
by an appearance of febrile paroxysms : towards
night the pulse oftentimes rises, and an inex-
perienced practitioner would consider the pa-
tient as affected by a true fever : but in a short
time this commotion of the arteries ceases or
abates, nor do these sudden glows of heat con-
tinue as long as real febrile paroxysms.

Again, there are other affections truly febrile,
which physicians call quotidians, because they
are plainly marked by daily recurrences or pa-
roxysms : they come on particularly in the
afternoon or towards evening : they are fre-
quently ushered in by a little chilliness or a very
slight shivering : sometimes, however, these
symptoms are entirely wanting, and then the

heat is neither intense nor dry and burning, but
moist, moderate, and unequally diffused. The
pulse is small, or at least but little elevated,
varying, however, in this respect, in different
eases. The paroxysms are sometimes longer
and sometimes shorter, they do not go off by a
plentiful sweat, nor do they in general terminate
in a complete apyrexy : some vestige of febri-
cula still remains. The urine is not latcritious,
but thin and transparent in the beginning, and
oftentimes continues so throughout the whole
course of the disease : at other times, however,
as the disease advances it becomes thick and
turbid.

These febrile affections, which are so very
frequent, are observed to occur in those persons
who labour under some obstruction, particular-
ly of parts situated in the abdomen. They at-
tack, for instance, such subjects as have diseases
of the liver or stomach, and also such as are
worn down by long watching, passions, or la-
borious exercises whether of body or mind.
Fevers of this description occur also in persons
who indulge in frequent debauches of the table,
as well as in those who waste their spirits and
consume their strength in pursuit of criminal
pleasures. Lastly, affections of this kind take
place also in females who labour under obstruc-
tions of the uterus or ovaria, and in such as suf-

fer greatly from a want of the menstrual dis-
charge. Even persons in very early life are not
exempt from these fevers. Girls of about twelve
years of age, or who have arrived at that period
of life when the catamenia are about to appear,
are particularly apt to suffer from them.

But although these fevers resemble intermit-
tents in their type, they are in reality altogether
different from them in their nature. They can-
not be considered as either double tertians or
triple quartans. In the former of these, the al-
ternate paroxysms, as we have already observed,
accurately correspond to each other. But
in the quotidians now under consideration, the
case is otherwise : besides, in the course of
these diseases, no positive apyrexy occurs ; nor
does the urine, in general, assume a lateritious
appearance : there is also an absence of certain
other symptoms which we have mentioned as
being attached to every genuine intermittent.
Finally, when the cure of these affections is at-
tempted by specific febrifuges,* the remedies
either produce no effect, or prove injurious. By
such treatment a hectic fever is sometimes pro-

* The term " febrifuge" occurs very frequently in the course
of this work. It is made to denote tonic remedies in general, but
more particularly the peruvian bark. It is seldom used, I believe,
by our author, without some reference to this latter article

Trans. '

duccd, which nature alone, or the use of gentler
remedies can subdue.

But, as quotidian fevers sometimes resem-
ble intermittents, so true intermittents assume
occasionally the appearance of quotidians. In
those subjects who have been long harassed by-
tertians, or who have had their diseases removed
by an unskilful mode of treatment, a certain
fomes still remains, by which, as evening ap-
proaches, a kind of febrile paroxysm is pro-
duced. But here obstructions for the most
part exist, occupying various parts of the abdo-
men. This fever, therefore, which arises from
the relics or remaining fomes of intermittents,
approaches very near to the nature of quotidi-
ans. It is generally rendered worse by the use
of febrifuge medicines, particularly if they be
possessed of heating or stimulating qualities :
nor indeed are remedies of this description ad-
missible at all, unless the functions of the affect-
ed parts be first restored.

Having stated the foregoing observations,
which are founded on actual experience, it
would be quite superfluous to go into the con-
sideration of all those circumstances which the
ancients have attributed to quotidian fever.
Respecting this form of fever nothing is to be
found in the genuine writings of Hippocrates.

Celsus, on the other hand, has given a tedious
account of it, and has described it as sometimes
regular and sometimes irregular in its type.
Galen who is more accurate on the subject,
has mentioned some of its peculiarities which
he had become acquainted with in a long course
of experience. That writer was induced by
various examples to attribute its origin to vis-
ceral obstructions. Yet I apprehend that in
some points he exceeded the bounds of experi-
ence ; for the disease does not occur as fre-
quently as the writings of certain physicians
would lead us to believe.

Mercurialis never saw this disease during a
most extensive practice of forty years duration.
Riverius very judiciously remarks, that out of
six hundred patients who sustained daily acces-
sions of fever, scarcely one experienced a real
quotidian : in the mean time he mentions some
of the characters and properties of that disease.
Thus, according to him, it produces a tension
of the praecondia, and may be protracted to the
fortieth day, or even to the expiration of the
second or third month : it is accompanied by
various symptoms, and degenerates at last into
some other disease, such as cachexy, dropsy or
lethargy.

CHAP. XIII.

Of affections, the mask or external character of -which
is sometimes put on by intermittents that have dege-
neratedfrom their own nature.

BUT if there are certain fevers which as-
sume occasionally the mask of intermittents, so
there are also other affections, the mask of
which intermittents themselves at times put on.
Sometimes the fomes or active cause of an inter-
mitting fever may lie hidden or be accumulated -
in a certain part, so that that part may appear to
be the only or principal sufferer : at other times
it may give rise to peculiar symptoms, in which
the whole force of the disease appears to be con-
centred : and, lastly, it may counterfeit other
diseases, which pursue a course peculiarly their
own, exhibiting no resemblance and possessing
no affinity whatever to intermitting fevers.

We will first adduce a few of the most sim-
ple and familiar examples on the subject. Some-

times, without any perceptible change in the
pulse, the most acute pains take place, and re-
turn at stated periods. Thus I have frequently-
observed an excruciating affection of this kind
situated above the eye, unaccompanied by any
other symptom. The commencement of this
pain is sometimes attended by a sort of palpita-
tion around the affected part. I have also met
with a kind of periodical opthalmia, which uni-
formly made its attack at a stated hour. Al-
though an inflammation of this kind does not
usually disappear in a short space of time, yet
in the affection under consideration the eye was
soon restored to its natural state.

We meet occasionally with cases of excruci-
ating periodical hemicrania, which are the off-
spring of intermitting fever, or, rather, which
are intermitting fevers converted into hemi-
crania. The whole head is also at times attack-
ed by a pain arising from the same source. I
once saw a person so dreadfully tormented with
a pain of this kind, as to be rendered almost in-
sane. At first view the nature of the affection
was not clearly discovered ; but, on a closer ex-
amination, it was completely unveiled ; for it
always made its attack towards noon, raged for
a few hours with great violence, and then re-
mitted.

But the febrile cause fixes itself not only in
the orbit, and in the eyes themselves, but also
on the external surface of the head. Indeed it
is capable of attacking every part of the system
separately. So true is this, that in some pa-
tients certain parts seem to suffer from fever,
while all the others are exempt from it. Some
of these parts are periodically affected by a sense
of coldness or heat ; others by convulsive or
tremulous motions, so various are the forms
under which the disease appears.

But, what is not less surprising, pains arising
from a febrile cause, yet unaccompanied by any
external signs of fever, oftentimes attack the in-
ternal parts of the body. I remember to have
seen a case in which a very acute pain in the
stomach, marked by periodical recurrences, was
at length cured entirely by febrifuge remedies.
This pain was accompanied by no change in the
state of the pulse, no preternatural heat, and
during its continuance the functions of all the
other parts of the system were unimpaired.

In general, however, things assume a differ-
ent aspect. When the febrile poison pervades
various parts, it usually produces in them more
or less fever* This poison is sometimes con-
fined, as to its sphere of action, to a few parts

of the body, and at other times attacks a greater
number of them ; it even occasionally passes in
succession from one part to another. I once
saw a patient who in the course of the same pa-
roxysm experienced the most acute pains in the
following order : they commenced in the legs
and thighs, then ascended towards the abdomen,
and finally to the head, producing a kind of apo-
plexy. There are still other and very dangerous
forms of disease, under which intermitting fever
sometimes masks itself. Most of these differ
so widely from its natural form, that in put-
ting them on, it would seem to have changed
its nature, and cannot even be detected without
difficulty.

This change or transformation of intermit-
ting fever may arise from various latent causes.
Whatever these causes may be, the febrile poi-
son is, under such circumstances, more active
and deleterious, and is diffused from its own
fomes over various parts of the body. This
diffusion appears from the erratic or wandering
nature of the poison, in as much as it may lie
hidden or be fixed in various places. These
observations are confirmed by troublesome ob-
structions which originate from the febrile poi-
son, and remain after the fever itself is sub-
dued.

But when, by the influence of these causes,
the attacks of the fever take on unusual and dan-
gerous symptoms, these do not generally appear
at the very commencement of the disease, but
show themselves, at furthest, in the third or
fifth paroxysm. In this stage of the disease,
either the cold fit cannot be removed at all, and
the patients sink under il ; or else a slight de-
gree of warmth takes place, but soon afterwards
the extremities become cold again. The func-
tions of the viscera are now variously disorder-
ed, some more, others less, to which succeeds
sometimes an inability to move, or else a toss-
ing and perpetual anxiety. Either of these states
denotes the utmost danger.

It is necessary to remark, that the pulse is
almost universally so small and frequent, that it
can scarcely be felt. I say, almost universally,
for there are some cases in which it possesses
more strength. Thus when a determination to
the head takes place, and the patients are attack-
ed by lethargic or comatose affections, the arte-
ries act with greater force. Their action is
equally strong when the disease assumes a rheu-
matic form. We must not be surprised at this
variety in the force of the arteries, since the fe-
brile poison exerts its power so variously.
Sometimes, for instance, this poison attacks cer-

tain parts of the body like a caustic, corrodes
them, and even draws from them discharges of
mucus and blood. In other parts again it excites
spasmodic motions or convulsions. This latter
mode of attack is very frequently met with in
practice.

The fever thus masked under such a foreign
or counterfeit form, may pursue a variety of
courses, and depart entirely from the common
fashion or type of paroxysms. Sometimes those
symptoms which have so unexpectedly taken
place, run on in form of a continued fever. At
other times, and that more frequently, they con-
tinue only for a few days, abating sooner or later
in different subjects. Under these circumstan-
ces the nature of the fever cannot be easily dis-
covered, for its symptoms do not perfectly either
remit or intermit. The oppressed parts do not
recover their proper tone, nor are their functions
restored to health.

But not unfrequently the febrile poison, even
when thrown on particular parts, preserves its
nature and acts conformably to its proper laws;
for it still attacks and remits periodically in the
form of paroxsms. Hence it appears that this
poison may be in some ?neasure subdued or dis-
sipated and exhausted, even without intense fe-

brilc action or any remarkable increase of heat :
I say, in some measure subdued, for there stilf
remain behind certain vestiges of these local af-
fections, which, in a subsequent paroxysm, pro-
duce for the most part symptoms of a more ge-
neral and worse nature. But, what is more
unusual, after a perfect intermission of seve-
ral days, the disease sometimes breaks out
afresh.

We must not suppose that the force of the
febrile poison, when wandering about and thrown
on certain parts of the body, manifests itself at
all times in the same way, or proves in every
case equally injurious. When the paroxysms
have been broken by the operation of febrifuge
remedies, it sometimes happens that the poison
or its relics are thrown on the external parts :
these parts are then attacked by pains more or
less severe, which are removed in no other way
than by a recurrence of the fever. But more
frequently the poison is thrown on the internal
parts ; in this case the abdomen swells, or the
functions of some of the viscera become dis-
ordered. But, in order that all things may be
restored to their natural and healthy state, it is
still necessary, in certain subjects, that there
should be a return of real fever : at least, in these
subjects, nature not unfrequently cures such

diseased affections in that way. Hence it
appears how greatly motion and heat contri-
bute to the subduing or elimination of febrile
poison.

CHAP. XIV.

Of the malignant form of Inter mittents.

AFTER what has been premised, we are
now prepared to enter on the history of malig-
nant intermittents. Oftentimes almost the whole
force of these diseases falls on the brain : the
patients become comatose ; the mind is disor-
dered ; a lethargy is induced, and, at times, even
a true palsy and apoplexy follow. In some
cases, (though this is a rare phenomenon) a kind
of catalepsy has been met with. We must not
be surprised, then, at the occurrence of convul-
sive motions, subsultus tendinum, tremors, de-
fects of vision, hearing, and other senses, or,
finally, an entire prostration of the vital prin-
ciple.

All these symptoms, so very unexpected, are
marked by variety in their origin, progress, and
decline. They sometimes proceed from a slight
and at other times from a serious and dangerous
beginning. In some cases their violence is such

from their commencement, that they appear to
be idiopathic, that is, altogether foreign from
the nature of an intermittent. But their true
nature becomes at length unmasked, for after
a certain time they usually remit, and then pro-
ceed in the form of paroxyms. In different
subjects the remission is more or less complete.
Some persons during the remission remain
heavy and almost senseless ; others labour un-
der a total loss of memory : but, what is less
frequently met with, some patients who in the
second paroxysm appear to be entirely free from
danger, experience, on the recurrence of the
third, all the alarming symptoms of the first.
Even when a perfect intermission has lasted for
several days, all apprehension for the future is
not to be abandoned; for, as we have already
observed, a relapse many times occurs, and the
whole phalanx of dangers breaks forth anew.
But these threatening symptoms may be subdued
either by the powers of nature or by proper re-
medies. At times they are carried off by a
diarrhoea or a copious discharge of urine. For
the most part, however, they yield to certain
remedies only.

The febrile poison falls not only on the brain,
but also on the organs of respiration. It less
frequently, however, attacks these latter parts,
nor indeed is the reason of this sufficiently un-

derstood. Wb.cn it docs attack them its mode
of action is not always tlic same. It mostly
excites spasms in them, which arc at the same
time communicated to other parts of the system.
But from these spasms, or from the irritating
and almost corrosive action of the poison arise
various pains. These sometimes attack the
diaphragm, and settle there, raging with the ut-
most severity. At other times they become
fixed in the sides, and occasion such torture to
the patients, as to render them unable to change
their position.

No wonder, then, if from these causes respir-
ation becomes confined and difficult, attended
with cough, panting, and shortness of breath.
Indeed, at times, the disease assumes something
of the form of suffocative catarrh or asthma, from
a congestion and oppression of the lungs by
means of a thick mucus. But it, occasionally,
appears in another shape no less formidable,
namely, that of a severe pleurisy or peripneu-
mony. The patient is then affected by a spitting
of blood, a fixed and lancinating pain in the
thorax, and a depressed pulse. This latter
symptom does not well agree with the preced-
ing one.

The stomach is apt to be a ye distinguished
sufferer from the action of the febrile poison.

Sometimes this organ becomes the seat of the
most intolerable anguish ; at other times of a
sharp and gnawing pain : you might suppose
it to be affected by inflammation or even erosion.
Hence arise nausea, and forcible, though fruit-
less efforts to vomit. In this state of the dis-
ease, the occurrence of deliquium animi, the face
and whole countenance being bathed in sweat,
a dimness of vision, a small and feeble pulse,
and a coldness of the skin, seem to threaten ap-
proaching death. Nor indeed is it possible for
the patients to survive, if these symptoms con-
tinue long, increase in force, or recur in several
successive paroxysms.

In the midst of these troublesome and dan-
gerous symptoms, a distressing vomiting often-
times occurs. The matter evacuated in this
way is bilious, yellow, porraceous, foetid, some-
times bloody and black, and is thrown up with
great force. In some patients similar evacua-
tions occur by stool, although the epigastric
region alone suffers pain and anguish. In the
mean time it is not in the stomach and bowels
alone that the force of the disease manifests it-
self. The tongue is scurffy, and the urine is
secreted in small quantity, owing to the spasms
that affect the kidneys. These spasms are com-
municated to the external parts and produce in
them various motions and effects. The same

symptoms therefore occur in intermitting fever
which take place in cholera morbus. There
exists, however, this difference, that in fever
these symptoms end when the paroxysm ends ;
whereas in cholera there is no such respite.

At times the febrile poison expends its force
not on the stomach, but on that portion of the
alimentary tube which is situated beneath it.
Hence arise excruciating pains, as if the intes-
tines were acted on by a caustic. The evacua-
tions by stool are profuse and various, being
either serous, bilious, or mixed. But in some
patients the acrimony of the irritating cause is
such, that the stools are mucous or bloody as in
dysentery : at times they are marked with pure
blood, and at other times they resemble the lo-
tara carnis, or water in which raw flesh has
been washed. To these symptoms great pros-
tration of strength succeeds. The patients are
affected with singultus, become cold, and lie
almost lifeless. A person inexperienced in the
disease, would scarcely believe it possible for
them to rise again. But, strange to tell, at the
termination of the paroxysm, these terrible
symptoms abate, and oftentimes entirely disap-
pear. In various diseases of the intestines, the
irritation remains even after the cause is remov-
ed, but when the febrile poison is dissipated or

exhausted, it seems to carry all its effects along
with it.

The force of the miasmata may fall on the
external as well as on the internal parts of the
system. Thus, papulae or pimples of various
kinds occur at times over the whole surface of
the body, and yield to the use of febrifuge reme-
dies. At another time the skin is suffused with
a deep red, which is lighter however in some
parts than in others. But more frequently a kind
of Sudor Anglic anus breaks out. In many
cases this flows abundantly from the forehead
and breast ; it is every where warm ; and the
more plentifully it flows, the m'ore intense is the
fever. - After a certain space of time, sometimes
longer, sometimes shorter, the sweat becomes
cold ; the pulse is depressed and in some cases
creeping. Under these circumstances, some
patients experience a tightness and oppression
about the praecordia, others a sense of heat and
burning in the stomach, while all are affected
with restlessness, tossing, and a suppression of
urine. The appearance of the body itself be-
speaks impending danger, for the flesh becomes
of a livid or blueish colour.

When the fever is ushered in by a severe
chill and shivering, the patient is usually attacked

by pains in various parts of his body. Ilence
it appears, that in whatever form the febrile poi-
son makes its attaek, it may ultimately produce
the same kind of affection. In those profuse
sweats of which we have just spoken, the sick,
sometimes experience in their legs and thighs
such sharp and excruciating pains, that the parts
would seem as if pierced with a sword. In cer-
tain cases a kind of rheumatic pain is diffused
throughout the whole body, in others it settles in
some particular part, and in others again wanders
about from place to place. Though this pain
seems to be the leading symptom, yet it is ac-
companied by various others. In some patients
it produces deli qui um animi, in others spasmo-
dic affections, and is not unfrequently attended
with inflammatory local affections, which shift
from one part of the body to another.

But if the febrile poison may prove injurious
to certain parts, and even become fixed in them,
it may also attack the vital principle itself, and
derange the whole economy of the system. This
is the case in those persons who labour under
an alarming syncope during the paroxysms of
the disease. Under these circumstances the
countenance is cadaverous, the eyes are closed,
the respiration is laborious, and every thing
seems to threaten immediate dissolution..

But there are cases in which the principle of
life and motion does not seem to be so imme-
diately attacked as the source of heat. Some-
times when the paroxysm is ushered in by a cold
fit, no hot fit succeeds ; at other times, after the
hot fit has commenced, it is gradually extin-
guished again. The external surface of the
body has then a marbled appearance, the counte-
nance a leaden cast, the extremities are livid,
and, to embrace every thing in a few words,
all those symptoms occur which are met with in
the malignant causus.* There are also at times
accidental symptoms which do not uniformly
prevail, such as intense thirst, a dullness and
feebleness of intellect, a diminished flow of
urine, &x.

In the proteiform course of intermittents
many things occur different from all we have laid
down on the subject. But we thought it best
to mention nothing except what has fallen with-
in the limits of our own experience. Our ob-
servations are confirmed by those of the cele-
brated Morton, and also by those of the very
learned and accurate Torti. But there is ano-
ther more ancient and very respectable physician,
who has considered with no less discernment

* A name given by the Greek physicians to ardent or inflamma-
matorv bilious fevers.

the metamorphoses or irregularities of intermit-
ting fevers. I allude to Salius Diversus, who
has paid the greatest attention to these diseases,
and from whose writings it will not be uninter-
esting to extract the following paragraph.

" In the commencement of some intermit-
tents, says he, while the patient experiences a
slight chilliness or shivering, such a great retro-
cession of heat occurs, that the skin becomes
quite cold, the countenance like that of a person
in a dying state, and the pulse so small and fee-
ble as to be scarcely perceptible. As the hot
stage comes on the pulse increases a little, but
is still small, unequal, frequent, and weak : the
thirst is obstinate and distressing, with great
anxiety, dejection, and restlessness : the sense
of heat to the patient himself is intense and
burning, while to the touch of another person it
is either imperceptible or very slight : there is a
great debility or alienation of mind, with cold
sweats, palpitation of the heart, and trembling.
As the febrile paroxysm declines all these al-
arming symptoms abate, and at the very com-
mencement of the decline of the paroxysm, the
pulse rises, and the heat returns. The paroxysms
of these fevers continue at times for sixteen or
eighteen hours, and I have observed that, on the
irights preceding the paroxysms, the patients
though not feverish are restless and uneasy."

Valesius has also had occasion to witness
the deleterious power of similar fevers, and has
expressly denominated them malignant. Louis
Mercatus has given their history in a very able
and definite manner, laying down with great
clearness and precision their diagnosis and prog-
nosis, and delineating their proteiform nature
and various appearances with such accuracy, as
to render it evident that there is no form of dis-
ease which they cannot assume. Deriving his
knowledge on the subject from his own exten-
sive experience, not from the writings of others,
that author omitted scarcely one of all those
symptoms that are apt to deceive physicians or
prove destructive to patients.

CHAP. XV

Of the change of Intermittents into Remittents and

continued fevers.

OF the foregoing description are oftentimes
those affections, the form of which intermitting
fever assumes; but that disease can also put on,
and lie concealed under, the mask of other fevers,
which seem to be equally foreign from its nature.
That physicians may be able to detect it under
every possible mask or disguise, we make a few
farther remarks on its various appearances and
various courses or types.

Most physicians are of opinion that an inter-
mittent may be joined or associated with other
fevers : almost every one, for instance, thinks
that he has seen it joined with a true quotidian;
but a true quotidian very rarely occurs, and it is
extremely difficult to distinguish it from other
forms of disease. How, then, can any* one

100

ascertain, in a satisfactory manner, that it is join-
ed to a single or double tertian ? Must it not lie
concealed under the symptoms of its associate
diseases ? All the ancients, and many modern
physicians who lived before the time of Harvey,
were too much devoted to theory. They fan-
cifully believed in the existence of a commixture
or conflict between phlegm and bile, and asserted
that as the one or the other of these gained the
ascendency, fevers of various descriptions made
their appearance.

The association of an intermittent with cer-
tain other fevers is a matter of less uncertainty.
It is occasionally joined with pleurisy, and pre-
serves its regular remissions and exacerbations.
I have also seen it, at times, go on in the same
regular periodical course, when associated even
with small pox ; but its junction with real con-
tinued fevers, which is so often spoken of, is a
circumstance not so easily discovered. Galen
very properly acknowledges the difficulty of ar-
riving at certainty on this point. For my own
part, I am inclined to believe, for reasons which
appear to me satisfactory, that such an associa-
tion is not only oftentimes suspected to exist
when in reality it does not, but that its exist-
ence is even contrary to the principles of na-
ture.

101

Opinions on these subjects should be drawn
from observation and reasoning. That an inter-
mittent may indeed become a continued fever
cannot be denied. When it assumes a type
that is not natural to it, the time of its continu-
ance in that form is various and uncertain. It
runs on for eight, eleven, fourteen, or even
twenty days. It is the form, however, and not
the nature of the disease that is changed. It is
still marked by paroxysms more or less evident,
and which return at stated hours. Besides, it
terminates for the most part in a true intermit-
tent, namely, in a single or double tertian.
Whence it appears, that there is no new disease
induced, but that the former one, which was a
continued fever, has lost one part of itself, or is
divided into two distinct parts by means of an
intermission.

Nor does this change consist less with rea-
son than with experience. For, when the power
of the febrile poison is great, the paroxysms
must neeessarily be of longer duration : they
may even be so protracted as to touch or run
into one another. In such a case they assume
the appearance of a continued fever. But, in as
much as the violence of the disease increases at
stated hours, and there is a regular periodical
recurrence of certain symptoms, the intermittent
form and habit are still retained and manifested.

102

Besides, the paroxysms become daily shorter or
longer, sometimes so very long as to run into
each other. Still the disease is distinguished by
the violence with which the paroxysms com-
mence, and by a previous remission or sense of
coldness.

But that we may not be thought to digress
in pursuit of uncertainties, we will decline any
further disquisition on this subject. It is enough
for us to know that intermittents do assume the
appearance of continued fevers, that they resem-
ble them more or less closely, that a greater or
a less number of paroxysms succeed each other
without an intermission, and that the remissions
may be more or less evident and striking. There
is also a great diversity in the circumstances or
symptoms that usher in, as well as in those that
terminate, the paroxysms. In some cases a
chilliness occurs, while in others the patients are
entirely free from it ; the same thing is true with
regard to sweating, for sometimes the discharge
by the skin flows plentifully, sometimes very
moderately, and at other times not at all.

Hence we may understand what is meant by
remittents, subintrants, and double tertians con-
tinued. A remittent is a disease in which, after
a paroxysm has continued for a time it abates,
until at or near to a stated hour another pa-

roxysm takes place. A sul /intrant is a disease
in which the first paroxysm has not terminated
when the second commences, so that each pre-
ceding paroxysm seems to run into each suc-
ceeding one.

Hence it appears that subintrants and re-
mittents are diseases of the same kind, differing
only in degree ; or rather, that they differ only
in name, being in reality the very same. As
to double tertians continued, they are diseases
which run on in a continued form, but are
marked besides by daily exacerbations occurring
at stated hours. Hence it is easy to see that
they are of the same nature with remittents and
subintrants.

Nearly allied to these is the semitertian,
which was so much dreaded by the ancient phy-
sicians. This disease, according to Hippocrates,
commences with a shivering, and is continued
and acute, but is lighter and more severe every
other day alternately. According to Celsus it
occupies thirty-six hours out of forty-eight, and
does not disappear entirely during the remis-
sion. In the mean time it has such frequent
accessions, that it might be taken for a disease
jf a different kind. But Galen has more accu-
rately said of it, that it is a continued disease,
but is marked bv an exacerbation and a chill

104

every third day; he says that it consists of two
fevers, a tertian, and a continued quotidian, and
occupies forty- eight hours in its period.* In
some things, indeed, that writer seems to con-
tradict himself, and this is particularly observa-
ble in what he has here and there written on the
subject of the semi- tertian.

From these ciscumstances, or rather from
the hidden nature of this form of fever, many
disputes have arisen respecting it among
more modern writers. Some have endea-
voured to ascertain clearly the sentiments of
the ancient physicians on the subject ; to
these many have added something of their
own, derived either from opinion, or observa-
tion. Some, for instance, have conceived
that two paroxysms occur on the same day ;
this wras the case with Riverius, who even
makes mention of a quadruple-tertian being
joined with a continued quotidian. Others have
suspected the continued fever to arise from an
inflammation of some viscus, and have derived
from thence the shiverings that sometimes suc-
ceed each other. All these writers, however,
agree that the disease is a compound of a ter-
tian and a continued fever, and have attributed

* The word " period" as used in this place, includes both the
paroxysm and the succeeding- interval of remission. These two terms
of time added together make up the space of forty-eight hours.

105

to the joint influence of these two, certain
inequalities and irregularities by which it is
marked.

Feeling but little interest in these controver-
sies, we will not enquire into the minutiae of the
sentiments of former writers respecting this dis-
ease, but only how their general sentiments
agree with what we derive from observation.
The febris hemitritaa or semitertian fever,
then, we consider as a continued double tertian.
Such however is the peculiarity of its type, that
one of its paroxysms is ushered in by a cold fit,
while the next is not, and so on alternately. It
is also accompanied by wandering and uncertain
rigors and shiverings, which occur more or less
regularly at stated hours. Hence it appears that
the hemitritasa or semitertian fever is a disease of
a malignant aspect, and approaches somewhat to
a malignant causus.

In the same point of view was this disease
considered both by the ancients and their im-
mediate successors. Hippocrates pronounces
it fatal, and says that it is accompanied by vo-
miting, tremors, and a sense of burning at the
stomach. Galen represents it as extremely dan-
gerous : the pulse in it, he observes, is slow and
crawling, the heat forsakes the extremities and
retreats to the central parts of the body, particu-

106

larly to the abdomen and thorax, and it is at-
tended with a comatose disposition, or with de-
lirium and watchfulness. By Rondeletius it is de-
nommatedfebris syncopdlis, BySchenkius it is
described as of a pestilential nature. Spigelius
declares it to be a real pestilence. Forestus was
accustomed to meet with it during the preva-
lence of malignant fevers. Valaeus considered
the rigors and tremors, with which he generally
observed it to be accompanied, as strong evi-
dences of its malignity.

No wonder, then, if the several descriptions
of the semitertian, as given by medical writers,
should differ widely from each other. All the
symptoms which we have enumerated do not
occur in the same case of fever. In some cases
more of these symptoms are manifested, in
others fewer, and in others again symptoms al-
together different appear. At times the disease
is introduced by a severe chill, at other times by
a slight chill or shivering. In some instances
cold and hot fits succeed each other alternately,
and the exacerbations or paroxysms are nume-
rous and frequent. Whatever symptoms are
unfavourable in intermittents, (and we have al-
ready said that the symptoms of this description
are various,) are dangerous when they occur in
the semitertian. Hence the signs and evidences

107

of malignity in these two diseases are alike plain
and intelligible.

Of nearly the same kind arc the febres tri-
taiopbia, a sort of tertians so called by Galen,
but which nevertheless approach nearer to re-
mittents, and are therefore more mild. Yet
even these are oftentimes dangerous, particular-
ly when they have irregular and inordinate exa-
cerbations. But there are other fevers closely
allied to these, which are no less dangerous,
namely the febres ardentes, or causi, of the
ancients. These, as Galen observes, carry with
them conclusive evidence that they are tertians
in disguise : in this alone do they differ from
common tertians, namely, that they are not
ushered in by a cold fit, nor do they perfectly
intermit. It is certain, however, that they ter-
minate in tertians or true intermittents, from
which, if we regard the name, they appear not-
withstanding to differ very widely.

CHAP. XVI.

Various observations adduced in confirmation of the
foregoing opinions and doctrines.

HENCE it appears, that intermittents may
be masked by and of themselves, as is the case
when they put on the form of continued fevers
or remmittents. But, that their disguise, how-
ever various, may be more readily detected, and
their nature more accurately understood, I will
endeavour to give a faithful history of those that
have fallen under my notice in certain epidemic
seasons.

The summer of a certain year having been
warm and dry, fevers prevailed extensively in
the autumn. These fevers took on, at first, a
continued form, but retained it for only five or
six days: they resolved themselves then into
true intermittents. In the autumn of the fol-
lowing year, the fevers generally commenced
with the type of double or single tertians, but

109

soon degenerated into continued fevers of fifteen
or twenty days continuance. During this pe-
riod various paroxysms occurred, in some cases
at stated hours, either at night, early in the
morning, or, not unfrequently, in the afternoon.
Occasionally the paroxysms were lighter, and
more violent on alternate days. It was not un-
common for the sick to suffer three exacerba-
tions on the same day, or on alternate days.

Seldom in these fevers were the exacerba-
tions preceded by a regular cold fit. Yet some
patients experienced at their commencement, a
slight sense of chilliness : in such cases,
the fever did not rage with so much vio-
lence, as in others, where the paroxysms were
not introduced by a chill. Ultimately, however,
these fevers were for the most part changed into
regular or irregular intermittents. Some per-
sons remained tolerably well during the day,
but were attacked by fever on the approach of
night. Many others experienced various symp-
toms, which it would be altogether superfluous
to enumerate at present.

Two years afterwards another epidemic pre-
vailed, in which the diseases assumed the form
of triple tertians. In these, the exacerbations
were preceded by a cold fit, which furnished sa-

110

tisfactory evidence of their being of the nature
of intermittents.

In this epidemic, however, the fevers did not
always assume the same type : their symptoms
were also different ; I saw many cases where the
disease, without any previous cold fit, ran on
like a continued fever till the eleventh, four-
teenth, or twentieth day. In these cases nothing,
in general, occurred till towards their close,
from which it could be inferred that the disease
was of the nature of a remittent ; then it seemed
to abate at stated times, and to be marked by
lucid intervals. Still, however, the violence of
the paroxysms was such as to threaten the sick
with the utmost danger.

In the spring of the following year, fevers
assumed a different aspect. Most of them were
slight in the beginning : for the first six or ten
days they pursued a continued course, without
manifesting any thing of an intermitting or re-
mitting type : the paroxysms were severe, and
not preceded by any cold fit, unless perhaps in
certain cases, where the patients experienced a
slight chilliness accompanied by something of a
cough : this disclosed to us the nature of the dis-
ease. At times the fever took on the form of
an irregular intermittent from its very com-

Ill

mencemcnt. The same type was assumed by
those attacks of disease which began as continu-
ed fevers and changed to intermittents ; they
became at last a kind of double tertians.

In these continued fevers I have observed
an appearance different from any yet mentioned.
In many persons several remissions and exacer-
bations occured on the same day : in others a
sense of heat and cold continued to succeed each
other alternately, for several days. At length,
however, these fevers were changed into true
remittents or intermittents, as well as the others
of which we have treated. But there were cases
in which, without this alternate vicissitude of
heat and cold, the fever continued to rage with
great violence for three or four days or more :
a remission then took place, which lasted one
day or perhaps longer : after this the fever re-
turned again, and raged without intermission for
three or four days longer. Most frequently,
however, these remissions and exacerbations
succeeded each other in such a way as not to
constitute any regular type of fever.

Hence it appears that all these epidemics
may be reduced to the following kinds or de-
scriptions of disease. 1. Genuine intermit-
ting fevers. 2. Fevers which are changed
into remittents. 3. Fevers which assume at

112

first a continued form, although they originate
from the real cause that produces inter mittents.
4. Others which, from having been intermit-
tents, become continued fevers. 5. Fevers
which run on in a continued form for five or six
days or even more. 6. Those of the same
nature that run on as continued fevers for fifteen
or twenty days. 7. Fevers marked by re-
missions longer or shorter, more or less con-
spicuous, and sometimes not even obvious to
the senses. 8. Fevers with exacerbations
sometimes preceded by a cold fit, and sometimes
not. 9. Fevers altogether irregular both as to
exacerbations and remissions.

CHAP. XVIL

Further observations setting forth the variety and
danger of such fevers.

AMONG the most remarkable epidemics
within my recollection, I will mention one which
originated from a very extensive pond filled
with putrid substances. Previously to the dis-
ease to which I allude, the neighbourhood where
it prevailed had been infested by fevers such as
we have just described : but there occurred at
length a remittent inclining to a continued form,
in the paroxysms of which the head was greatly
affected. This disease was, for the most part,
marked with great oppression at the breast and
about the precordia, delirium, and convulsions :
it oftentimes assumed the appearance of true
apoplexy, but more frequently that of lethargy :
at times the sick lay motionless, deprived of the
exercise and power of their senses ; not unfre-
quently the paroxysms commenced with severe
head-ache, and the most excruciating pains in the

114

joints. On the remission of the fever all these
symptoms abated, and sometimes the sick ap-
peared to be quite out of danger.

At other times the disease assumed an as-
pect somewhat different ; the febrile symptoms
ran high, with an acute pain in the side : the
breast, as in peripneumony, was oppressed with
a heaviness and a difficulty of breathing : in
some cases there was a continual and very dis-
tressing vomiting : in others, suffocating sensa-
tions, pains in the bowels, and such like symp-
toms, raged with great violence during the whole
course of the paroxysms : besides spasms and
convulsive motions, many of the sick were sub-
ject to syncope ; most of them to such extreme
debility, that they seemed ready to expire;
seme of them indeed lay as if already dead ;
during this great prostration of strength, the
surface of the body wras cold and of a marbled
appearance.

In all these cases the force of the pulse was
various. At times the violence of the symp-
toms wras so great, as to break in on the regular
course of the paroxysms and render them ob-
scure ; the pulse was then contracted and weak,
as if there had been a deficiency of vital energy ;
but at other times, and that most commonly, the
febrile symptoms were high ; under these cir-

115

cumstanccs the pulse was strong and very fre-
quent ; in some instances, however, it was less
elevated, and struck the lingers with less force:
still it was sufficiently forcible to show of itself
that the fever was very high.

In the following year a fever of the same
kind became prevalent. It was a double tertian
and continued subintrant. In this disease apo-
plectic and lethargic symptoms came on at the
very commencement of the cold fit, and, such
was their force, that they continued throughout
the whole course of the paroxysm; but as the
paroxysm passed off, the sick revived as it were
from this deplorable condition, and returned to
the exercise of their senses and their intellect :
you would have sworn that they had suffered no
injury. So great was the remission of the fever
and the intermission of the bad symptoms, that,
provided the subjects were young, they did not
at first view appear to "be sick : but when ad-
vanced in years, their situation was much more
dangerous, and unless art came opportunely to
their relief, they soon fell victims to the dis-
ease.

Three years afterwards I met with another
epidemic of the same kind with, or at least not
very dissimilar to, the foregoing ones. This
disease prevailed throughout the summer and

116

autumn, and proved extremely fatal in its course
But that its symptoms may be the more clearly-
comprehended, I will describe a few curious
cases of it : from these it will be easy to judge
of the great variety that may occur in the effects
of febrile poison. It will appear, in particular,
how dangerous this poison may be, even in
cases where the sick entertain the most sanguine
hopes of a recovery, and where no danger can
be apprehended from the violence of the dis-
ease.

A young woman was attacked by a remit*
ting fever. In the third paroxysm she became
insensible; her lungs were oppressed, her breath-
ing became stertorous, and in eight hours she
died. The fate of my next patient was no less
unfortunate and melancholy. He had been at-
tacked by a double tertian fever. During the
third paroxysm he fell into a delirium which
continued for three days. During the day his
fever was moderate, but it encreased on the ap*
proach of night, arid put a period tQ his exist,
en ce.

Another person was attacked by a remitting
fever, somewhat inclined to become a continued
one. On the fifth day, he fell into a lethargy or
coma, and an oppression of the breast coming
on, he expired, In a certain female subject, a,

disease of the same kind assumed a different ap-
pearance, and pursued a different course. The
patient was attacked, for instance, by a genuine
intermittent; but on the fourth or fifth pa-
roxysm her mind became deranged..., she con-
tinued in that state, without much fever, for
six days, and then recovered her senses ; but
the fever again encreasing, she was carried off
by the next paroxysm.

A certain gentlemen ill of a remitting fever,
put himself under my care. He had daily a rigor
and shivering : at length on the fifth day, he fell
into a lethargy which continued for twenty-four
hours. By degrees, however, he recovered his
senses, and was of a sound and firm mind for
one day, but a shivering and paroxysm occur-
ring again, he died of a kind of asthmatic suffo-
cation. No less unexpected was the fate of
several other patients, who, after moderate pa-
roxysms, became cold on the surface of the
body and were seized with faintings ; their
strength then failed entirely, and, after suffering
great oppression, they expired,

It appears from the foregoing circumstances,
that these fevers attack more particularly the
brain, the seat of the intellect, but that they
also do great violence and injury to the lungs,
Nor are the pra?cordia less affected, and even

118

the heart itself is a great sufferer. In a word,
even the vital principle is attacked and over-
whelmed, as it were, by the febrile poison, and
from hence are to be deduced the dangerous
symptoms which the sick experience : these
symptoms are so violent, particularly in persons
advanced in years, that, unless the greatest at-
tention be paid to them in the commencement
of the disease, they run on to a fatal issue.
Youthful persons more readily recover ; yet
many even of them are carried off either
through a neglect of remedies, or by the force
of the disease proving superior to the resources
of art.

It may be thought singular in these diseases,
that sometimes from so slight a beginning, the
danger should become so urgent and threaten-
ing in the course of a few days. But it is a
problem no less difficult to solve, how a cause
which so disorders the brain, and so oppresses
the lungs, can of its own accord give the sys-
tem a temporary respite, or cease for a time to
act. Thus, after the third or fourth day the
action of this cause is suspended, and for a day
or more the patients seem free from disease.
Other maladies do not pursue such a course ;
in them the affected parts recover only by de-
grees ; and after they have recovered, or appear
to have recovered in the space of a day or two,

119

the life of the patient is seldom brought into
clanger again by a sudden return of the disease ;
at least this is not generally the ease, as it is in
malignant intermittent.

Hence may be deduced a rule or conclusion
of no small moment in acute diseases. It ap-
pears, for instance, that there may be great
disorder in the functions of the body without
either real inflammation or any fixed disease in
the solid parts. Many patients are delirious,
raving, and appear to labour under a peripneu-
mony, others suffer the most excruciating pains,
while others again have their stomach and
bowels greatly disordered; they appear, indeed,
to be in as much danger as if they were la-
bouring under the greatest inflammation, un-
der a wound, or some strong irritation about to
extinguish the vital principle ; yet those parts
which had experienced such deep and distress-
ing affections, may in a short time be entirely
relieved. Hence it appears that these terrible
symptoms may arise from some wandering sti-
mulus, which flies off and returns, or acts and
lies dormant, alternately ; and that they are
sometimes more alarming in appearance, than
dangerous in reality.

CHAP. XVIIL

#
Of the method of detecting or distinguishing Intermit*
tents when disguised under the mask or appearance
of other diseases*

HAVING thus delineated the different
phases or appearances of intermittent s, and
given an accurate history of the symptoms
under which they are usually masked, it remains
that I should mention the signs by which the
nature of these masked diseases may be detect-
ed. They possess, for the most part, such vio-
lence, that unless their nature and tendency be
well understood, they may prove highly dange-
rous to the persons whom they attack.

The origin and nature of these fevers may
be known from their modes of attack : if they
have intermitted or only remitted, and after-*
wards returned and run on with unusual symp-
toms, there is ground to suspect that they are
masked diseases. This suspicion will be con-

121

verted into certainty, if the exacerbations should
be ushered in by a cold fit. But should there
be nothing but a slight chilliness, recourse must
then be had to other signs, for the disease exhi-
bits only the appearance of a continued fever
marked by periodical exacerbations. But there
are many fevers of this description, that have no
affinity to remittents.

But if fevers, which are even not ushered in
by a cold fit, be marked by paroxysms sudden-
ly occurring, if the patients, when apparently
well, be attacked instantaneously as if they had
received a blow ; if stretchings and pains of the
head, instead of a cold fit, precede the paroxysms,
under these circumstances, there is good reason
to believe that the disease is an intermittent un-
der a masked form.

The same conclusion is to be drawn relative
to the nature of the disease, when it has pa-
roxysms that are succeeded by a striking remis-
sion. So great, at times, is the violence of these
paroxysms, that they are accompanied with real
danger, whereas during their remission, which
is quite a lucid interval, the patients seem to be
in no danger whatever. Under such circum-
stances, there can be no doubt but the diseaae
is a remitting fever wearing the mask of a con-
tinued one.

122

The nature of the fever is equally manifest,
if the exacerbations terminate in a copious
sweat ; if the paroxysms return about the same
hour ; if they exactly correspond with each other
every day or on alternate days ; if there occur
very violent and alarming symptoms which ap-
pear and terminate periodically, such as deliri-
um, fierce ravings, lethargy, most acute pains in
the head, a failure of strength, tormina of the
intestines, Sec.

Lastly, masked intermittents, may be no less
certainly detected, as was formerly observed, by
the colour of the urine. In that disease the
urine is very often lateritious, which is a sign,
almost infallible, that the disease belongs to the
family of intermittents. But the urine is lateri-
tious only during the remission ; whence it
ought to be attended to and examined with the
utmost care.

The following instances wilt show with what
confidence these signs may be depended on, and
how readily the disease may be detected amidst 1
the various and unusual symptoms that attend
it and render it obscure. I once attended a fe-
male patient, who was thunder-struck, so to
speak, by hysterical affections, tormented with
pains shooting through her whole body, and ap-
peared indeed on the point of dissolution. Da-

123

ring this prostration of strength, some paroxysms
suddenly occurred, which convinced me that
the disease was an intermitting fever in disguise.
I, therefore, had recourse to febrifuge medicines,
which soon restored my patient to health.

I once attended another female patient who
laboured under an hsemopthisis : she had an
acute pain in her side ; and was reduced to a
state of extreme danger by means of various and
repeated exacerbations. But when I was in-
formed that the disease had commenced with a
chill, and that some of the earlier paroxysms had
terminated in a sweat, I immediately determined
on the exhibition of febrifuge remedies, which
in a short time removed the fever, and all the
symptoms that had appeared so formidable.

A gentleman whom I once attended in a very-
severe pleurisy, experienced unusual and peri-
odical exacerbations. These exacerbations came
on not by degrees, but very suddenly. Besides,
during the paroxysms there was a copious dis-
charge of blood from the mouth, a symptom
which is extremely rare. In this state of things
I conceived an opinion, that all the unfavourable
appearances of the case were owing to the latent
cause or fomes of intermitting fever, and that a
cure was to be accomplished only by febrifuge
medicines. This practice was accordingly adopt-

124

ed, and the patient who had been in the utmost
danger, was in a short time restored to health.

A gentleman accustomed to hunting was at-
tacked by a fever of extreme violence. In a
short time he fell into a fierce delirium, and ex-
perienced a burning heat, and a restlessness that
nothing could restrain. But as these symptoms
alternately increased and abated in violence at
stated periods, I began immediately to suspect
that the disease was a masked intermittent. Re-
course was had without delay to febrifuge reme-
dies, to which the disease soon yielded, although
it appeared to have been aggravated by other
modes of treatment.

A young female was attacked by a continued
fever somewhat inclined to remit : but the re-
mission was so short and slight as to be scarcely
perceptible. In the mean time the danger was
extreme. Such was the violence of the pa-
roxysms that the patient seemed ready to ex-
pire. Alarmed at this dangerous state of things,
the first lucid interval that occurred although it
was very short, I exhibited febrifuge medicine
in large quantity, and that not without advan-
tage, for all the symptoms were rendered much
milder.

Other examples of the same kind might be
adduced, but the foregoing are sufficient for oil*

125

purpose. I must not, however, omit to mention,
that during the prevalence of an epidemic inter-
mittent, I am pretty generally led to suspect that all
cases of fever partake more or less of the nature
of intermittents. When there is no general pre-
valence of intermittents, the periodical return of
exacerbations, the disease being one day milder
and the next more severe, an evident remission
however short it may be, and a sudden recur-
rence of violent symptoms.... these circumstan-
ces, I say, furnish me in general with satisfactory
evidence that the fevers are intermittents in dis-
guise. On such occasions the urine retains in
many cases nearly its natural colour.

CHAP. XIX,

Of the consequences to be apprehended from the leading
symptoms of the fevers wider consideration.

FROM masked forms of fever let us return
to true intermittents, and enquire into their ef-
fects and dangerous relics or consequences.
Those relics or consequences which we shall
enumerate are not uniform occurrences, for
such are the nature and powers of the animal
economy, that the fever itself generally returns,
and does away all danger. But the dangers
which we are about to mention in this place are
not to be considered as necessarily attached to
every case of intermitting fever ; they are only
such as do or may occasionally take place in the
course of this disease.

We have already enquired into the immediate
effects of the cold fit, and cannot, therefore, be
ignorant of the dangerous consequences to which

127

it is likely to give rise. There is no doubt, in-
deed, but from the constriction which it induces,
and the consequent stagnation of blood in the
lungs and liver, these parts are pre-disposed to
various obstructions, and irregular states of ac-
action. Hence the liver is so often diseased.
From the constriction of that organ, the bile
does not pass freely through the ducts : the pa-
tients become livid ; the digestive powers of the
stomach are weakened ; and some of the other
viscera are injured in a similar way, and render-
ed unfit for the performance of their functions.

But the greatest violence may be done to the
heart. Its ventricles together with the vena cava
may be much enlarged. Hence the palpitations
and polypous concretions, to which those per-
sons are subject, who have laboured under severe
and long continued intermittents. The mass
of blood stagnating in the lungs may prove
equally injurious. It produces occasionally a
spitting of blood, or a kind of asthma. These
symptoms do not, indeed, very frequently occur.
It is sufficient, however, that they may occur.

There is still, as we have already intimated,
another point of view in which the power of the
cold fit proves highly dangerous. It depresses
the vital principle in such a manner as to ren-
der it at times incapable of re-acting: hence this

128

principle is, sometimes, so completely over-
whelmed, that the patients die under the influ-
ence of the cold fit. Nor is this, indeed, to be
wondered at, when the pulse either ceases to
beat, or becomes small and frequent, when res-
piration is disturbed, and, lastly, when the fluids
stagnate in the brain and in various other parts
of the system. Hence the sick are in real danger,
in cases where the cold fit is of long duration. I
'have seen many persons reduced to such an
alarming state, that without medical assistance,
they would necessarily have expired. To pa-
tients who are in the prime of life the cold fit of
an intermittent is not so often dangerous ; but
to persons advanced in years it is very frequent-
ly so.

The danger arising from the hot stage of fe-
ver is not so great. As soon as a sick person
has escaped from, or passed over the cold stage,
he is usually considered as safe. But is there
not a secret taint introduced into, or generated
in the system, which increases by degrees, and
at length breaks out when not expected ? In an
intermitting fever, a tertian for instance, the heat
of the body rises as high as the 39° of Reaumur,
and higher still in compound fevers. But if in
a person in health the temperature should rise
equally as high, every day, or every other day,
and ' continue at that degree for six or eight

129

hours, would he be free from clanger, even al-
though he should enjoy the usual temperature of
the human body during the remainder of the
day and night ?

On this point we may form some opinion,
from the effects usually produced by a high de-
gree of heat. What a rarefaction takes place in
the texture of the softer parts of the body ?
What a distraction or laceration of the more
tender fibres ? What a change in the fluids,
which are the source of heat ? In as much as
men and other animals are oftentimes destroyed
by passing through high degrees of heat, it is
wonderful that sick persons are not more injured
by the great burning that occurs in intermitting
fever.

But however patients may seem to escape
danger, when parched by a strong febrile heat,
the organs of the body and their functions are
necessarily injured by it. Some patients are
subject to great agitation and tossing during the
hot stage of the fever : others again suffer the
most distressing anxiety about the region of the
heart. The burning heat that exists in the lungs
proves equally troublesome and oppressive. The
head itself feels as if on fire, and there is no doubt
but the very tender medulla of the brain suffers
from this intense heat.

130

How great then is the injury that may be
clone to these and other parts of the system,
which are burnt up, as it were, by this febrile
fire ? Were we to trust to theory alone, the dan-
ger would indeed seem to be great and immedi-
ate. But experience and observation teach us,
that the powers of nature are such as ought to
prevent us from despairing of the fate of the sick
in these scorching fevers. Unquestionably, how-
ever, the system must suffer much from the in-
tense heat of the paroxysms, and their frequent
returns must pave the way to many diseases.

In summing up the causes that tend to the
injury of the system, we must add the action of
the vessels, which corresponds to the degree of
heat, and which, during the course of the pa-
roxysms, is so great, that the frequency of the
pulse is doubled, and the degree of heat greatly
increased. Hence we may infer, in general,
what the vessels themselves suffer, both the
larger ones, and the capillaries which terminate
in a tender pulp. The texture and function of
the glands and other parts are necessarily injured.
From the increased rapidity and force in the mo-
tion of the blood arises a most acute pain of the
head, with a more frequent and difficult respira-
tion. But a circumstance still more dangerous
is, that there is a kind of congestion formed in the
vena portse and liver ; for it is not practicable for

131

the blood to circulate through the intricate u lad-
ings of that organ, as rapidly as it flows from the
arteries into the veins.

Sweats, even when profuse, do not portend
the same degree of danger. But although they
contribute greatly to the relief of the system
when the paroxysm is declining, they do not en-
tirely remove the cause of the fever. Even the
relief which they afford tends to exhaust the sick.
Suppose, for instance, a person in consequence
of some error in diet, or after a debauch in eat-
ing should sweat very profusely for three or four
hours every other day ; could such an event ul-
timately contribute to health ? or would it not
rather be attended with danger, since it is known
by experience that five or six pounds of the
fluids of the body are discharged through the
pores of the skin during that space of time ?
There can be no doubt as to the effect on the
system in the case of febrile sweats, when pro-
fuse, long continued, and frequently repeated.

Nor are the fluids discharged by the skin
simply aqueous, although if they were, even
then their loss would be injurious : the thicker
juices themselves, which are destined to the nou-
rishment and reparation of the system make
their escape; whence the vital organs are neces-
sarily debilitated. Sick persons are sometimes

132

so greatly disposed to such discharges from the
skin, that they flow copiously without any known
cause, particularly during the night. Even after
the fever is removed, this disposition to sweat
frequently continues, and can scarcely be check-
ed. But, what is of more consequence, there
still remains, under such circumstances, either
some fomes of the disease, or else a local affec-
tion of some particular part of the system.

The thinner parts of the fluids, in particular,
having escaped by the cutaneous pores, it is evi-
dent that those which remain in the vessels are
more gross ; a circumstance which seems to
threaten no small degree of mischief to the sys-
tem. On this theory, however, too much reli-
ance must not be placed. The grosser parts of
the blood are at the same time dissolved or
made thinner, a circumstance which, taken in
conjunction with the influence of the febrile heat,
tends to keep it in motion. This dissolution
is greatly promoted by acrid and alkalescent bile,
which, being regurgitated into the blood, is dif-
fused throughout the vascular system. The
other humours of the body are also rendered
acrid, as appears from pustular eruptions which
occur about the mouth. Hence patients who
have laboured long under fever, appear blood-
less and pale.

133

The change in the humours appears also
from the urine itself. During the febrile action,
that fluid is flame-coloured, as already mention-
ed, but, as the paroxysm declines, becoming
thick, frothy and very red, it puts on at length
a brick-dust colour. This colour appears in
particular in the sediment which is generally
copious. The sediment is nothing but a red-
coloured earth, as I have oftentimes ascertained
by experiment. This earthy sediment is apt to
lodge and create a temporary obstruction in the
vessels of the kidneys.

This kind of urine belongs so peculiarly to
intermitting fever, that, provided the disease be
genuine, it is seldom wanting. Indeed there is
no solid reason to believe that the system is free
from the fomes of the fever, while the urine re-
tains its lateritious colour, or is in any measure
tinctured with red. This phenomenon does or
can prove fallacious only in cases where the sick
labour under some hepatic affection. If at any
time the urine should exhibit a white matter
settling copiously to the bottom of the vessel,
this is to be considered as a favourable symp-
tom, and even a sign of a crisis in the disease.
I must confess, however, that this phenomenon
has but seldom fallen under my notice.

134

In some intermitting fevers the urine does
not assume a lateritious colour. I allude parti-
cularly to certain vernal intermittents, or to
those that change into continued or remitting
fevers. Even in these, however, the urine does
exhibit something of a lateritious appearance
during their remissions. At those times, when
the secretory vessels of the kidneys are suffered
to relax, in consequence of an abatement of the
febrile spasm, the grosser and red coloured par-
ticles are allowed to escape. Whence it ap-
pears, that at the commencement of the disease,
if it be very severe, the urine does not depart
from its natural colour, but assumes a red
and lateritious cast when the symptoms abate.*

* Physicians, like other characters, are apt to fly from one ex-
treme to the other. In former times the appearances of the urine
of sick persons were, perhaps, on all occasions, too closely and too
credulously consulted ; at present they appear to be too much ne-
glected. Such a copious and important excretion must very gene-
rally exhibit certain characters, that might serve as something of an
index to the state of the system. By paying a proper attention to
the appearances of the urine, I am persuaded that physicians might
oftentimes discover and predict the crises of diseases, much to their
own credit, and to the benefit of their patients Trans.

CHAP. XX,

Of various affections attendant on Intcr?nittents.

WE have now seen what is to be appre-
hended from each leading symptom properly
and necessarily attached to intermittents. It
remains to ascertain what those affections are,
which, not being attributable to any of the
symptoms in particular, must be referred to
them all collectively, or rather to the disease it-
self, taken as a whole. These affections are not
indeed perpetual, or uniform, because they may
cither occur or be wanting : but it remains to
be enquired what injury they may do, when pre-
sent, to certain organs of the body.

It is very common in intermitting fever, for
patients to experience pains in the head, some-
times slight and at other times extremely acute.
It would seem, at first sight, that the violence of
these pains is to be attributed to the impetus of
the blood against the brain. But that is not the

136

cause to which the mischief is to be always refer-
red. The blood circulates, at times, with ex-
treme violence without producing any such affec-
tions of the head. We have already mentioned
that the febrile poison oftentimes attacks the
seat of the intellect, producing convulsions, le-
thargy, and even madness. For the same rea-
son it stimulates the membranes of the brain.
Hence arises the most excruciating pain, which
usually rages during the actual continuance of
the fever, and ceases during its intermission.

Other patients are heard to complain of af-
fections of the stomach. That organ is affected
with nausea, vomiting, and loathing of food, or
with a sense of heaviness, burning, and tight-
ness. Some patients experience in it at the
same time pains of different kinds. But a
symptom which occurs no less frequently, and
is of no less importance is, a distension or
swelling of the stomach. This symptom is some-
times met with even in intermittents that have
not been of long duration, and continues in many
cases after the febrile symptoms have terminated:
but it occurs most frequently in those which
have been of long continuance, or which have
been treated in an injudicious manner.

But we more frequently meet with a swell-
ing of the abdomen or lower belly, which as-

137

sumcs a variety of appearances. It is sometimes
soft, and at other times the integuments appear
like dry parchment ; but most frequently the
abdomen is very much distended. On some
occasions its hardness and resistance to the touch
arc so great as to resemble marble. Notwith-
standing this, it is as true as it is surprising,
that on these occasions, there can be nothing-
found in the abdomen but air distending the in-
testines by its elastic force.

All these symptoms proceed, for the most
part, from some derangement in the functions
of the liver. The secretion of bile, for instance,
is either checked or diminished, or that fluid be-
comes acrid and unfit for the business of healthy
digestion. If the fever be of a higher grade, the
sick sometimes complain of a sense of heaviness
and anxiety thence arising, or of severe pains
in the right hypochondrium. Some persons
suffer a slight attack of hepatitis. Hence we
plainly perceive why the countenance becomes
yellow or livid, and how readily an intermitting
fever may be succeeded by a jaundice, a circum-
stance which frequently occurs in certain epi-
demics.*

* Attacks of jaundice were uncommonly frequent ftJDOftg the
citizens of Philadelphia during the winter of 179^-4. The |
position to that complaint had heen produced by the maligna

138

There are many other troublesome symp-
toms which originate from the same source. It
is not to be wondered at if such a serious affec-
tion of an organ so necessary to life should prove
highly injurious to the surrounding parts ; if it
should render the intestines tumid, and cause
even the external parts of the body to swell. In
some epidemics I have seen this swelling occur
as early as the eighth or ninth day of the disease.
In general, however, it makes its appearance
later, and arises, like dropsy, from some morbid
affection of the viscera.

But the liver proves the cause of still further
evils in the course of intermitting fever. With-
in the texture of this viscus the blood accumu-
lates and there stagnates. That blood which is

Hemic of the preceding- autumn. In its future occurrences the
malignant fever was not productive of jaundice to the same extent.
The explanation of this fact does not appear very difficult. During
the epidemic of 1793, but few of our physicians treated the disease
by copious blood-letting and purging. Hence hepatic congestion
was not in general sufficiently removed. Of this remaining conges-
tion jaundice was a natural consequence. On all subsequent occur-
rences of the malignant fever, copious blood-letting- and purging
were more generally adopted in practice. Hence the liver was un-
loaded and consequently obstruction and jaundice prevented. I be-
lieve it may be laid down as a principle to which there is no exception,
that proper and timely evacuations will always prevent bilious aifec-
tions of every description from terminating' in either jaundice or
dropsy Trans.

139

thrown into the vena portae cannot go forward :
the other parts of the abdomen therefore must
necessarily become turgid, because the blood
which flows constantly into them, is subject to
a similar stagnation or delay. The spleen in
particular becomes turgid, and is oftentimes
greatly increased in bulk : the parietes of the
stomach and intestines become thickened, and
the mesentery also is subject to tumefaction.
From this state of things arise obstructions, pu-
trid diarrhoeas, dysenteries, and dangerous dis-
charges of blood. All these symptoms frequently
occur in certain epidemics and in fevers of long
duration.

Hence it appears that the force of flatus not
only distends the abdomen, but also increases
the size of the viscera. The blood and other
fluids being accumulated and made to stagnate
in certain internal parts, are converted into solids
and thus augment the bulk of these parts. The
truth of this will be demonstrated by the dissec-
tions of which we shall speak hereafter. We
must not be surprised, therefore, at finding the
abdomen to appear uneven, filled as it were with
tumors, and much harder than in a natural or
healthy state. From the irritation of the fever
some decree of rigidity cannot fail to occur in

O Da

tliis part.

140

It is much more surprising that, during the
existence of this abdominal tumefaction, the fe-
ver in many cases not only remits, but even
ceases altogether or changes its nature. When
the febrile poison exerts its force on the viscera
of the abdomen, it appears to desert the other
parts of the body, or rather to act on them in a
different way. The same thing takes place in
swellings of the lower parts, of which we will
treat presently. When such swellings occur,
the fever disappears or gives ground to hope
that it soon will disappear. But this exemption
from fever is not universal. In some subjects
the fever continues, even when the abdomen,
the lower extremities, and other parts of the
body are greatly tumefied. Under such circum-
stances a new disease is superadded to the ori-
ginal one.

Although the foregoing effects of intermit-
ting fever are very distressing, we must not
consider them as necessarily fatal. Youthful
persons who are most subject to them, and who
are sometimes so reduced bv them that death
appears inevitable, do, notwithstanding, often-
times recover from them, and that sometimes by
the powers of nature alone. In adults also,
when the functions of the abdominal viscera are
so much diseased, that it seems scarcely practic-
able for the relics of life to be continued any

141

longer, remarkable recoveries sometimes occur.
Many persons by the proper administration of
remedies, and many others by a change of cli-
mate, and even by the approach of summer are
restored to such perfect health, that no one
would suspect them to have been indisposed.

From these circumstances it would seem that
the obstructions arising from intermitting fever
arc of a peculiar kind, and not so dangerous
as those arising from other causes. Hence
remedies may be administered and hopes in-
dulged even in cases of the most unpromising
aspect.

CHAP. XXL

Of affections which remain after the febrile form of the
disease has been removed.

SO much for those affections which occur
during the course of intermittents. But there
are many others, and those of no inconsiderable
moment, which remain after the febrile form of
the disease has been cured. Thus, some pa-
tients are subject to a most acute and distressing
pain in the head. To such a height does this
pain sometimes arise, that the whole original
disease would seem to be changed into it. The
patients sometimes declare that the head feels as
if it were cleft asunder in the middle. Under
such circumstances it cannot be supposed that
the whole of the febrile poison is eliminated from
the system. In some instances, however, after
baving' given rise to such excruciating pains.

143

it is dissipated cither by the spontaneous powers
of nature, or by the aid of diluents alone.

At other times, after the febrile symptoms
are gone, the whole body seems as if it would
melt away. At night, in particular, the sweats
are so profuse and oppressive, that they exhaust
in a short time the strength of the system. Dur-
ing this deluge, it is a great error to suppose
that the fever is cured : the febrile cause seems
to be only thrown on the skin. At times, in-
deed, sweats may occur from mere debility of
the system ; but they never flow in such abun-
dance, unless some morbid cause be acting on
the viscera. By such a fomes the discharge by
the skin is rendered so profuse that it can
scarcely be restrained; and if it be restrained
by an unskilful mode of treatment, the step
proves always injurious to the patient, as I have
learnt from repeated observation.

Of all the complaints that remain or can re-
main after the fever is removed, by far the most
troublesome are the morbid affections of the vis-
cera. Indeed when we consider the great pow-
er which the febrile poison sometimes pos-
sesses, we cannot be surprised at certain vestiges
of it remaining in the system for a considerable
time. These show themselves more particular-
ly in the liver; and from that organ arise many

144

affections, from which the sick are with great
difficulty relieved. There are also other parts
of the system in which very troublesome and
grievous relics of the disease remain : the pan-
creas becomes indurated ; the spleen is enlarged ;
the intestines with difficulty recover their healthy
functions ; the appetite is weak ; the strength
is exhausted ; and the countenance is overcast
with a livid or yellowish hue.

Hence it appears how readily this disease
may be succeeded by a watery swelling in va-
rious parts of the body. As soon as the vio-
lence of the fever abates, the feet and legs in
many cases become cedematous. This effusion
into the cellular membrane takes place, partly
from the obstructions that remain, and partly in
consequence of the force of the febrile poison
being determined to the lower extremities.
Hence the occurrence of a watery swelling of
this kind may be considered as a sign that the
fever is declining. Youthful persons are not sc
subject to swellings of this nature. Indeed such
affections occur most frequently among persons
in indigent circumstances, either because these
subjects are deprived of the advantage of able
medical aid, or because their bodies, being
worn out by fatigue, are thereby rendered more
liable to obstructions.

145

This swelling of the feet and legs oftentimes
degenerates into true and general dropsy ; and
oftentimes into an anasarca only. But it occurs
in certain epidemics more frequently than in
others. Last year, for instance, was remark-
able for swellings of the feet, legs, arms and
hands : the lungs themselves were oppressed by
the effusion ; sometimes the difficulty of breath-
ing was very great : the sick were harrassed
by a troublesome cough, particularly in cases of
general anasarca. These affections occurred
more frequently as the consequences of irregu-
lar intermittents.

Occasionally, however, they are produced
by simple intermittents. A man aged thirty,
was lately ill of a tertian fever. The disease
having been neglected for several months, as-
sumed an irregular type. It was at length suc-
ceeded by a general anasacra, which no remedies
could remove. What seemed most surprising
in this case was, that on dissection scarcely any
disease was discovered in the viscera, which
could be considered as the cause of the anasar-
cous swelling. Hence it appears, that an uni-
versal diffusion of the febrile poison can produce
an universal and fatal effusion into the cellular

membrane.

CHAP. XXII.

Of relapses in Inter mittents,

FROM these affections of the viscera in in-
termittents, it is evident that the febrile poison
may, for a long time, remain in the system, and
produce frequent and unexpected returns of the
fever. So subject are patients to relapses in this
disease, that, in the opinion of some persons,
great precautions ought still to be used on the
day and at the hour of its usual occurrence. It
has been observed by certain writers that after
the entire solution of the fever, and even after
a long intermission of its paroxysms, those pa-
roxysms are apt to recur about the same hour
of their original commencement, in case any im-
prudence be committed about that time. I will
not vouch for the perfect accuracy of this ob-
servation.

147

Be these circumstances as they may, it ap-
pears from actual experience, that if the fever be
not radically cured, it does not give a respite of
more than fourteen or fifteen days.* This,
however, is not always the case, but it is to be
considered only as a general rule. Sometimes
the disease grants a much longer respite ; thus,
for example, the patient is not unfrequently ex-
empt from it throughout the winter, and attack-
ed by it again in the spring : it disappears a
second time during the summer months, but
returns again in the autumn, unless prevented by
proper remedies. In the intervals between those
periods the disease is oftentimes excited into
action by various causes.

But as these causes are various, so are also
the febrile relapses which they produce. Often-
times when the prospect of a recovery is very
flattering, all the symptoms return as at first :
the paroxysms for instance recur with various

* Intermitting' fever lias certainly a strong disposition to return
at K.;cekty periods, for a considerable time after the suspension of its
paroxysms. The knowledge of this fact is of much importance both
to physicians and their patients. By using- proper precautions at
these periods, the return of the disease may be easily prevented.
As a week is about the fourth part of a lunation, some physicians
have attributed this hebdomidal recurrence of intermittents to lunar
influence. Conformably to this opinion, they contend that the dis-
ease manifests the strongest disposition to return about the full and
change of the moon. Be this matter as it may, there appears to be
but little reason to doubt the reality of at least some degree of lu-
nar influence on the human system.... Ti -an*.

148

degrees of force and duration ; in a certain time
they cease again and are again renewed, but
sometimes with more irregularity than before.
The disease now and then assumes the form of
a remittent or a continued fever, and afterwards
returns to that of an intermittent. Thus it
oftentimes runs on for a great length of time,
harassing the sick by various and irregular
symptoms.

These circumstances may occur at any time,
but they happen most frequently during the
prevalence of epidemics. I have met with these
alternate appearances, and with this alternate
cessation and return of the complaint, more es-
pecially in those fevers that rage in marshy situ-
ations. When these diseases have continued
for a certain time they scarcely admit of a per-
manent cure. Relapses happen on the most
trivial occasions. Oftentimes when the patients
seem to be nearly restored to health, that is, re-
lieved from the paroxysms, they are suddenly
carried off by the disease. Others drag on with
difficulty a wretched existence from autumn till
summer. Nor are they all freed from the dis-
ease even then : many of them are only somewhat
relieved. In the mean time relapses are very apt to
occur, in consequence of the relics of the fever
that remain in the system, and the various
symptoms by which the sick are affected.

149

In these relapses the appearances are various.
The paroxysms recur indeed at stated hours
and on stated days, but without a perfect inter-
mission intervening. On the days of intermis-
sion some degree of fever still seems to prey on
the internal parts of the system. In some of
these cases, the sick arc scarcely able to sustain
themselves, having at the same time a pale and
yellowish appearance. The fever is a kind of
continued one, although marked with paroxysms
that pursue the usual order. Hence there seems
to be a two-fold cause of the disease or febrile
action ; one of these consists in a diseased affec-
tion of the viscera ; the other in the presence of
the miasma, which constitutes the fomes of in-
termitting fever.

In some instances, these diseases seem to in-
cline more to the form of hectic fever. The
regular periodical paroxysms cease, but the
pulse rises in the night, without either a cold or
a hot fit of any consequence. The intermediate
days are never free from some degree of fever,
particularly in those patients, who have been
treated unskilfully. Relics of the same kind are
met with in those who suffer frequent relapses
in consequence of an affection of the viscera, or
of the force of the febrile poison.

We will proceed no further in considering
the various kinds of relapses. But although in

150

certain cases they are so frequent and diversified,
it is still the opinion of some writers, that persons
who have once laboured under intermitting fe-
ver, and been perfectly cured by a true crisis
and proper remedies, are in general less liable to
it during the remainder of their lives than they
were before. There are at least very few per-
sons who have been subject to frequent attacks
of quartan fever. I do not mean by this, that
those who have been once subject to intermit-
ting fever have nothing to apprehend from epi-
demics, or from those places in which epidemics
of the kind usually prevail : for when their
bodies are surrounded by febrile miasma, that
poison cannot fail to make some impression on
them, notwithstanding their being less pre-dis-
posed to receive its action. The meaning of
physicians on this subject appears to have been,
that those persons who have once experienced
the effects of the poison of intermitting fever,
are not, in general, so susceptible of them
again.

Be this matter as it may, it appears from
what has been said, that there are two points of
primary consideration with respect to the relics
of intermitting fever. Either the febrile fomes
remains in the system and re-produces a regular
intermittent ; or some principal and important
parts of the system suffer serious local affections.

151

In these cases relapses are to be dreaded, and
when they take place do not easily admit of a
cure : or if the intermitting form of the fever be
removed, still the patients are apt to continue
infirm and sickly during the remainder of their
lives : in particular, obstructions of the viscera
remain, which greatly impede the performance
of their functions.

CHAP. XXIII.

Of the morbid appearances discovered in the dissection
of the bodies of those that have died of Litennitten

IN the dissection of dead bodies the fore-
going obstructions and local affections are dis-
covered. It is not my intention to treat of those
that are found in bodies that have died of a com-
pound remitting fever. In that disease the vital
principle is overwhelmed or extinguished by
the force of the febrile poison ; the head is se-
verely attacked ; other parts suffer great injury ;
the whole system is thrown into commotion by
spasms and irritation, and hence death is pro-
duced in the same manner as in continued
fevers.

But simple intcrmittents, or those that dege-
nerate into hectic or such like fevers, leave
rious vestiges of themselves in the bod v. Cer:

153

parts, however, they attack with more violence
than they do others. The head, for instance,
seldom exhibits any morbid appearances, al-
though it sometimes experiences the most ex-
cruciating pains.

But the organs of circulation and respiration
suffer greatly, as we have already mentioned.
The auricles of the heart, and the pulmonary
vessels are turgid with black blood. A great
congestion takes place in the minute lobules of
the lungs, and there is water effused into the
cavity of the thorax. In some cases the peri-
cardium is distended with water. This latter
circumstance is particularly observable in those
who die of intermitting fever in maritime situ-
ations.

As the stomach is so often affected with vo-
miting, it is no wonder, as already mentioned,
that it should be found greatly distended with
flatus. The distension and the irritation from
whence this distension arises, sometimes pro-
ceed so far as unquestionably to prove the cause
of death, by occasioning in many cases a spasm
of the parietes of the stomach. I have seen per-
sons who, when apparently free from fever,
have been destroyed by overloading their sto-
mach at supper. In these cases the stomach
was wonderfully distended either with flatus or

154

with water, or was overpowered by the quantity
of food taken in.

But the deepest ravages are found in the
liver. That organ is for the most part pale,
bloodless, and somewhat wasted away. At times,
however, it is enlarged in its size, indurated,
and variegated on its surface with small yellow
glands; at other times again it is turgid with
blood, and that very black. In some patients I
have found an abscess of the liver after tertian
fever ; while in others, again, I have seen the
vena porta? converted into a very large tube.
Many other affections of the liver are mentioned
by medical writers ; it has been found very
remarkably enlarged ; the ducts distributed
throughout its substance are entirely obstructed.
The gall-bladder is also found obstructed, and
distended with bile.

The pancreas is also subject to the ravages
of intermitting fever. In some dead bodies
only certain parts of that viscus are found ob-
structed; in others its whole mass is either
schirrous or greatly enlarged; some physicians
have seen it in a state of suppuration ; for this
reason, as I have elsewhere observed, they have
considered it as the great repository of the fomes
of intermitting fever. It is not, indeed, to be
wondered at, that obstructions should occur in

155

this viscus, since the blood stagnates, or at
least moves very slowly in the hepatic veins.

For the same reason the spleen has been sub-
ject to the same charge. Its bulk, for instance,
is sometimes greatly enlarged. I have even
known it to acquire this increase of bulk in a
short space of time. But, what seems more
surprising, that viscus has returned to its natu-
ral state again, by the exhibition of febrifuge re-
medies alone. But the spleen not un frequently
suffers another kind of morbid affection : it is
filled with black blood resembling tar or pitch :
it then runs into something of a gangrenous
state. A woman laboured under a neglected
quartan ; being destitute of the common com-
forts of life, she died suddenly. In the dissec-
tion of her body, the spleen was found in some-
what of a dissolved state ; and a large quantity
of blood was effused into the abdomen.

Hence it appears, as mentioned on a former
occasion, how liable to disease the peritoneum
and messentcry are ; in these parts schirri and
abscesses have been found. Having oftentimes
examined these parts, I have plainly observed
the glands of the mesentery in a diseased state.
In very young people, in particular, I have seen
these glands obstructed and greatly increased in
size. In the duplicative of the peritoneum va-

156

rious tumors occur, which either produce a con-
gestion, or are the effects of one. The fluids
in consequence of stagnating become consoli-
dated, and firm, and thus form a kind of steato-
matous substance.

In the intestines certain appearances are
observed, which may be attributed to the fever ;
these parts, as we have already observed, are
greatly distended ; but as they are distended in
some places, they are constricted in others. In
the colon, in particular, I have found various
contractions of its diameter, especially where it
passes over the left kidney, and dips down
again, previously to its terminating in the intes-
tenum rectum. From these contractions or
narrownesses many consequences arise, which I
shall not mention at present, as they may be
readily foreseen by every medical reader.

There are still other morbid affections which
take place after intermitting fever. These, taken
in conjunction with such as have been already
mentioned, enable us to judge whether or not
intermittents ought to be ranked among the sa-
lutary processes or states of action of nature.
That this is the case, many writers haveattempted
to prove, both by argument, and by the autho-
rity of the ancients. But can a disease be of
itself salutary, or can it be considered as such in

157

its nature and real tendency, when, during its
course, so much local injury is done to various
parts of the system ?

Theory is too oftentimes nothing more than
the visionary offspring of the imagination : it is
experience alone on which we can finally depend.
Many physicians seem to be convinced by ex-
perience that quartans contribute much to lon-
gevity. This only, in my opinion, can be main-
tained on the subject, namely, that intermittents
may sometimes cure certain other diseases.
There are, for example, relaxed or debilitated
bodies in which the motions and actions of the
internal parts of the system are too weak : there
are also certain nervous and convulsive affections
which may be removed by adding strength to
the motions of the internal parts: by this in-
creased motion, stagnations are removed; new
power is bestowed on the vital organs ; noxious
humours are thrown off by perspiration; a new-
eras is or constitution is given to the blood ;
and the whole habit of the body is changed.

A certain description of febrile paroxysms,
therefore may restore or confirm health. But if
these paroxysms be very severe and long continu-
ed, they not only will not prove salutary, but will
do mischief, and that the more dangerous in its
nature, in proportion as the system is more

158

weak and delicate, or more affected by other dis-
eases. Persons subject to jaundice, cough or
any other pulmonary affection, have no advan-
tage to expect from an attack of intermitting fe-
ver. This at least is generally true, nor can it
indeed be otherwise, unless there be in the sys-
tem certain noxious humours, which produce
these affections, and which may, by the action of
the fever, be changed or corrected.

BOOK SECOND.

OF THE

TREATMENT OF INTERMITTING

AND REMITTING FEVERS.

CHAPTER I.

Of the difficulty of curing Intermittents, and wherein
that difficulty consists.

IT now remains to consider the treatment
and cure of intermitting fevers. To many it
will seem scarcely necessary to touch on this
subject; for there is no one who does not con-
sider himself competent to the cure of these
diseases. A firm belief has hence arisen, that
few or no persons ever die of intermittents.
These fevers sometimes terminate spontaneous-
ly, or are in many instances easily cured ; nos-
trums for that purpose are in the hands of every
one, and are even publicly sold under the sanc-
tion of medical characters. Whatever precepts
and modes of practice, therefore, may be laid
down on the subject, will be considered by many
as an ostentation of learning.

160

But intermitting fever is sometimes ex-
tremely dangreous, and in many cases difficult
to be removed. The mode of cure itself may
prove injurious ; and numerous controversies
have arisen respecting the proper mode. As
there is no opinion, however ridiculous that has
not originated with or been supported by some
philosophers ; so there is no remedy, however
absurd and injurious, that has not been the se-
cret nostrum of some physician.

Nature herself appears to us to act caprici-
ously in the cure of diseases. Thus, fevers are
sometimes cured alike by heat and by cold ; in
some cases acrid substances, in others demul-
cents, effect a cure ; in some, wine and ardent
spirits, in others, copious draughts of water;
even poisons themselves have become celebrated
for various cures; finally, there is scarcely any
thing whether noxious or innocent, that has not
cured intermitting fevers. Even when these
diseases have been attacked to no purpose in a
rational mode of practice, it has not unfrequent-
ly happened, that they have been completely
subdued by a very preposterous and perverted
mode.

The road, therefore, which leads to the cure
of inter mittents, instead of being plain and easy,
is, oil the other hand, extremely difficult and la*

161

borious. The greater the number of remedies
appears to be, the easier it is to err in the ehoice
of them. That an opinion may be the more
readily formed respecting them, we will premise
a few considerations.

Those things that are not consistent with
themselves, or which do not generally succeed
in effecting a cure, cannot be considered as reme-
dies ; but of this description are many things
that are carried about and sold as antidotes.
Much more ought we to reject whatever may be
attended with any degree of danger, such as
acrid and heating substances, which are almost
always hurtful, even when they effect a cure.
The same thing must be said respecting reme-
dies of opposite powers. Of two remedies pos-
sessing contrary qualities, one must be hurtful,
particularly if their action on the system be
powerful.

From so many cures, which are attributed to
these remedies, it will appear that nothing can
be deduced, if we enquire into their true cause.
Such are the nature and principles of the febrile
cause, that at times nothing seems necessary to
the cure of intermitting fever, but some striking
and sudden change; hence fear or terror sudden-
ly induced sometimes eradicates the disease.
The same effect is produced by great heat, ex-

162

ercise, the use of acrid substances, &c. but
these arc not certain and well establish* d reme-
dies ; for, though they may succeed in one case,
they fail in many. Besides, if they do not hit
their mark, and destroy the fever as it were by
a single blow, they are sure to render it more
obstinate and dangerous.

Nor can even the remedies proper in inter-
mittents be safely exhibited unless with the ut-
most circumspection and care. There are some
remedies which may remove the disease, and
prove at the same time hurtful to the patient.
Hence the dissentions between physicians of dif-
ferent countries ; they trust and distrust certain
remedies, and that, at times, for reasons alike
unsatisfactory. Those physicians who even use
the same remedies, are scarcely able to agree re-
specting the proper method. Thus the lives of
their patients are sometimes exposed to danger
by their controversies.

Amid so great a variety of opinions, it is a
matter of no small moment to select the best me-
thod of cure. This method consists in the pro-
per use of two kinds of remedies, namely, those
which are called general, or common to other
diseases, and those that are specific, or peculiar-
ly suited to intermitting fever. The general
remedies, such as evacuants, diluents, and ape-

163

rientSj arc the most powerful ; by their use the
body is reduced nearer to its natural state. The
circulation of the blood is easier, the several
parts of the system perform their functions bet-
ter, and the depraved juices are altered or eject-
ed. Specific remedies, therefore, may be ad-
ministered most certainly and safely, after general
remedies have been premised. By these latter
remedies the way is paved for a cure, while by
the former the cure is accomplished.

CHAP. iL

Whether or not all Inter mitt ents are to be treated with
the same remedies ? Whether or not, when left to
themselves, they terminate or come to a crisis spon-
taneously ? and whether or not an attempt should be
made to cure them at their very commencement f ,

WE must now enquire whether or not every
intermitting fever ought to be treated in the
same manner. There is a wide difference be-
tween vernal and autumnal intermittents : their
nature is indeed the same, but the febrile poison
seems to be milder in the former than it is in the
latter : this, however, is not always the case,
for we sometimes observe vernal intermittents to
be possessed of a malignant character.

But, in general, these diseases of the spring
are easily removed. After having run on for a
short time, they very frequently terminate of
their own accord. An attention to regimen

165

alone is adequate to the eure of them. If they
require any remedies, neutral salts and other
aperients are for the most part sufficient. It
would seem that if there be any fevers of a salu-
tary tendency it must be these ; they open the
vessels and pores that have been obstructed du-
ring the winter ; they communicate motion to
the stagnating fluids, and, by means of febrile
action, either change them or discharge them
through the different emunctories.

Fevers happen also at other seasons of the
year which are by no means obstinate or difficult
to be cured. This arises either from these dis-
eases attacking persons of favourable habits of
body, and not abounding in depraved humours ;
or, what is very common, from the febrile poi-
son being extremely weak. In attempting the
cure of such diseases, but little can be done ; at
least a few remedies are sufficient, such as dilu-
ents, aperients, and mild purgatives. If specifics
be necessary, it is not requisite that they should
be exhibited with such great precaution. Thus
the method of cure ought to be suited to the cha-
racter of the disease.

Here a question of great moment arises,
namely, whether or not, if intermittents be left
to themselves, they admit of a spontaneous cure ?

16(3

Some writers believe that they terminate after
the seventh paroxysm, and that they have a fixed
period of duration as well as continued fevers. I
am, indeed, of opinion, that if in intermitting fe-
ver the patients be confined to a strict regimen,
such as is usually prescribed in acute diseases,
the intermittent will soon come to a close. Se-
veral examples have occurred to convince me
of the truth of this. But to do away every re-
maining doubt on the subject, it would be ne-
cessary to confine a certain number of sick
persons to this regimen alone without any other
remedy.

But, (a circumstance which is less doubtful)
if, during the observance of such a regimen,
gentle remedies be administered, these diseases
are in general very easily cured, provided they
be not marked with great violence ; and provi-
ded there be no serious epidemic prevailing. But
there is a necessity for using the remedies just
mentioned, because there is frequently too much
blood in the system ; because the primae viae
abound with depraved humours ; and there is
sometimes a great accumulation of bile. All
these impediments must be forthwith removed,
in order that nature may be able to do her work
spontaneously, and by her own inherent pow-
ers.

167

If nature be thus dealt with and regulated,
she usually brings about a kind of crisis in the
disease. The third paroxysm is more severe
than the two preceding ones, but the sixth is
the most severe of any. The seventh, which is
generally the last, grows milder, but is succeeded
either by a gentle sweat, or a diarrhoea, or the
morbid cause is carried off by both these modes
of evacuation occurring at the same time. Some-
times these efforts of nature occur several days
;ifter the seventh paroxysm. It must be acknow-
ledged, however, that in many cases no critical
evacuation can be observed. This happens
more particularly when the system is disturbed
by a multiplicity of remedies, or the febrile
symptoms subdued at once by their specific
power.

There arises another question of no less con-
sequence relative to the use of both general and
specific remedies in these diseases. It is enquir-
ed, for instance, whether or not it be best to
attempt the cure of intermittents immmedi-
atvlv on their commencement, or to suffer them
lo run on unmolested for a certain length of
time ?

We do not here allude to those patients on
whom intermittents may have a salutary effect.

168

If these complaints are likely to eradicate some
other disease, they may then, indeed, be left
to nature for some time. But if they attack
persons in health, will they, under these cir-
cumstances, prove serviceable to them ? and
whether will it be better for those attacked to be
relieved from them, or to suffer the poison of
them to rage through their systems ? We are
persuaded from every view of the subject, that
the poison ought to be eliminated from the body
as soon as possible.

I am in the habit of paying particular atten-
tion to the force and character of the fever, and,
as soon as I discover that it cannot he subdued
without difficulty by the powers of nature, hav-
ing first prepared the system in the proper man-
ner, I have immediate recourse to specific
remedies. Nor have I ever, in the course of
many years, known any mischief to arise from
this mode of practice. Even fevers of a bad
aspect have been removed without leaving any
vestiges of themselves behind. On this circum-
stance alone the issue of the matter entirely
depends, namely, that the medicines be skill-
fully administered, and the system properly
prepared for them by a diluting, cooling, and
opening regimen. I acknowledge, indeed, that
if physicians have recourse immediately to ft-

169

brifugC medicines, and those of heating quali-
ties, they will, in many instances, do mischief;
but it docs not follow from thence, that inter-
mittents ought for a certain time to be left to
themselves. When thus neglected they gene-
rally take deeper root and become more obsti-
nate and difficult to be cured.

CHAP. IIL

Of Blood-letting.

THE first remedy that presents itself is
blood-letting. Yet it must be confessed that this
alone is not a cure for intermitting fevers. It
is, therefore, that it is so often spoken of unfa-
vourably, and accounted altogether useless : if
some writers are to be credited, it is even to be
considered as injurious. Perhaps this opinion
has been derived from the effects of very copious
hemorrhages, which, at times, have appeared to
add strength to these fevers. It does not, how-
ever, follow from thence, that blood-letting is
to be entirely rejected, as if incapable of doing
good in such diseases.

On this subject nature and experience fur-
nish us many things worthy of notice. I have
oftentimes seen double tertians converted into
simple tertians by a single blood-letting. Half

171

of the disease, therefore, may be removed by the
loss of blood. But, what is of no less moment,
T have learnt from certain and repeated observa-
tion, that the paroxysms are rendered much
milder by it, and made to recur at a later hour.
Besides, after blood-letting, the febrile heat is
less distressing, the sweats are less profuse, the
pain in the head is milder, and all the functions
of the body go on with more regularity.

It may be laid down, therefore, as an esta-
blished principle, that if venesection does not
absolutely cure intermittents, it paves the way
for other remedies, and is on that account ^high-
ly necessary. It remains, therefore, only to be
-determined, whether or not it be necessarv in all
oases, whether it may not be, or rather ought
not to be omitted in some, and, finally, what are
the limits that ought to be set to it ?

It would, indeed, be absurd to have recourse
to blood-letting in every febrile affection. There
are cases in which it is allowable and even neces-
sary to abstain from it ; these are such as are
mild in themselves, or such as attack persons al-
ready Aery much exhausted and debilitated.
Fevers of this description stand the less in need
of such a remedy, in as much as many of them,
and those of a serious aspect, have been occasi-
onally cured without blcod-lctting. 33ivt these

172

few examples ought not to divert our attention
from the precepts of reason and the result of ex-
perience. It is safer to have recourse to blood-
letting even when not absolutely necessary, than
to neglect it when it is necessary.

It would be particularly injurious to omit
blood-letting in cases where the blood-vessels
are turgid, the fever intense, and the patients dis-
tressed with a burning heat, or, an extremely
acute pain of the head : by such an omission
the fever would be rendered worse, and the va-
rious functions of the system probably injured.
To the neglect of blood-letting is the obstinacy
of fevers to be generally attributed ; from this
source must we oftentimes derive the failure and
even hurtful effects of febrifuge remedies. It ap-
pears from the best founded experience, that a
fulness of blood, an impetuous circulation, and
the febrile heat thence arising are unfavourable
to the success of such medicines.

How far blood-letting ought to be carried,
it is impossible to state. This depends on the
constitutions of patients, and the violence of
their symptoms. In as much as these circum-
stances may be various, so may the amount of
blood necessary to be drawn ; at times, indeed,
it must be large. The nearer the fevers approach
to a continued form, the more frequently must

recourse be had to the remedy of blood-letting.
This precept, which is founded on experience
and reason, shall here be illustrated by a few
examples.

In an epidemic constitution which once pre-
vailed in this place, the fevers were double ter-
tians, and many assumed even the appearance of
continued fevers. In these the sick experienced
no relief till after three or four blood-lettings.
In many cases the pulse was so hard, and the
pain of the head so acute, that the practitioners
were obliged to repeat the blood-lettings five or
six times. If this remedy was neglected, the
heat was intense and burning; the pains of the
head were intolerable ; and the disease generally
put on a true continued form. But after the
tone of the system had been reduced by blood-
letting, all the symptoms soon remitted, and left
an opening for the exhibition of other remedies.

In tertian fevers of a spurious and violent
kind, I have oftentimes met with a similar occur-
rence. When blood-letting was used too spar-
ingly, the symptoms were usually rendered
worse ; it was in vain that relief was looked for
from other remedies. But when practitioners,
urged to it by the obstinacy of the disease, had
recourse again to blood-letting, after having used
it too sparingly at first, the state of the sick was

174

immediately changed for the better, the heat
abated, and the paroxysms became more mild.
Other remedies which had before been exhibit-
ed to no purpose, now succeeded in producing
a cure.

In the mean time, in simple intermittent s,
and even in double tertians, provided they do
not assume a continued form, one or two blood-
lettings will be generally sufficient. Nor ought
the practitioner to go beyond this, in case the
apyrexia between the paroxysms be perfect, and
the fever during the paroxysms so moderate that
it can to appearance be borne, without any ma-
terial injury t>eing done -to the functions of the
body.

But, under what regulation shall blood-let-
ting be used, in those intermittents which dis-
appear for a certain time, and then recur again ?
must it be had recourse to as often as they thus
make their appearance ? It would seem useless
and improper to continue to lose blood in cases
where it has been frequently lost already ; in
cases where the disease has oftentimes disappear-
ed for a few days, and then returned again ;
where its long duration has brought on a cha-
chectic habit of body ; and where, from the
summer or autumn it has been protracted to the
midst of winter. Finally, to include every thing

175

in a few words, the strength of the system ought
to be such as to be able to bear blood-letting, nor
should we ever have recourse to it unless com-
pelled by the violence of the symptoms.

We have already observed that blood-letting
docs not eradicate the cause of the disease, but
merely curbs its violence. But what benefit can
be derived from such a check, in cases where the
vital energy is already too languid ? The objec-
tions which we here raise can serve only to re-
strain imprudence. No one but a madman will,
in treating a febrile complaint, persist long in at-
tempting to overcome it by very profuse blood-
letting. To this practice, when carried to ex-
cess, the king of Spain is said to have fallen a
victim, and from the same cause several others
have, to my certain knowledge, shared the same
fate. I do not mean, by what is here said, that
blood-letting is to be rejected in every case of
fever of long standing. If the pulse demands or
admits of it, if the febrile symptoms run too
high, it becomes unsafe to neglect this remedy.

CHAP. IV.

Of cleansing the prima: via:.

BOTH before and after blood-letting, a very
light diet must be strictly enjoined, and that even
on the days of intermission. This is necessary,
at least in the beginning of the disease, and must
be considered as laying the foundation for a per-
fect cure. At the same time diluents must be
used, in order that the system may be properly
cleansed ; for evacuating medicines do not act
with success, unless aided by a plentiful use of
aqueous drinks. The use of such drinks is
particularly necessary to persons inured to ex-
ercise, and such as are plethoric, bilious, and of
a dry temperament. In addition to these dilu-
ents, recourse should be had to injections, for
the purpose of evacuating the lower intestines.

These things being done, measures must
now be taken to cleanse the primae viae, and the

177

whole intestinal tube. The fomes of the fever
does not indeed reside in this part of the sys-
tem : but the disease may be rendered much
worse by depraved, putrid, or bilious humours:
by such humours the blood is vitiated, an acri-
mony is created in it, and heat and irritation are
produced ; at least from them arises some impe-
diment to the efficacy and success of febrifuge
remedies. Experience bears testimony to the
truth of this, because, while the stomach and
intestines are overloaded with crude humours,
the cure of intermittents continues to be diffi-
cult. Affections which may be easily removed
after proper evacuations, take deep root and be-
come obstinate if such evacuations be omitted
or neglected.

But with which ought we to begin, emetics,
or cathartics? It will perhaps to some seem,
best to refrain from emetics, because, at the
commencement of the paroxysms, the sick are
subject to painful and repeated vomiting. Add
to this, that whatever offensive matters remain in
the recesses of the stomach, must be necessarily
expelled by the efforts and kind offices of nature.
But experience has taught us that such efforts
are useles ; for the fever continues, notwith-
standing, extremely violent, and recurs at stated
periods. This febrile vomiting, therefore, not

only is not useful, but even does mischief, be-

i a

178

cause in the commencement of the fever there
is a general constriction of all parts of the
system ; hence the stomach cannot be properly
evacuated ; it is only affected by a morbid ir-
ritation, which distressess it, and subverts its
action*

The cure of the disease, therefore, calls for
a vomiting to be excited by art. It has been
already demonstrated that the liver is very par-
ticularly affected : it becomes the seat of a col-
lection of vitiated bile : the blood stagnates in
the branches of the vena portae ; and unless this
stagnation be removed, it will operate in con-
junction with the vitiated bile like a second
ibmes of disease, which readily produces fever.
But we cannot with more certainty remove this
stagnation and bilious congestion, in any other
way, than by emetic medicines : for when these
excite vomiting, the liver is, as it were, in a
press, where it is agitated by alternate and re-
peated concussions. By such pressure and con-
cussions the blood is forced out of its small ves-
sels, while the bile is pressed into the intestines,
and from thence with the other juices of the sto-
mach discharged by the mouth.

This medicine appears particularly neces-
sary in certain fevers, or in certain epidemic
constitutions ; for the sick throw up vast quan-

179

lities of green, tough bile, similar in consistence
to very thick oil. But what is truly surprising,
or at least of great moment, so rapid is the for-
mation of this bile, that to vomit once is seldom
sufficient ; for after a short time, such a fresh ac-
cumulation of bile takes plase, that another pa-
roxysm of vomiting occurs as plenteous as be-
fore. But as often as this redundancy of bile
returns, so often does fever also recur ; whence
it can be made to appear by many arguments,
that the disease is actually kept up by the bile,
a fluid it) other respects so necessary to the
system.

Nor is there any doubt but stagnations also
occur in other parts of the body. That this is
true, appears from the power and influence of the
cold fit, and also from the irregularity and in-
creased force of the circulation. The same thing
may be inferred from the obstructions that so
often follow intermitting fevers. But the circu-
lation of the fluids is greatly promoted by the
influence and operation of emetic medicines.
These medicines rouse the nervous energies, and
throw into action the capillary vessels through-
out the whole system. Hence the fluids which
had begun to stagnate and grow solid, as it were,
in the extreme vessels, are again urged onward
in the course of circulation.

180

All these things are confirmed by innumer-
able experiments. Emetic medicines are, indeed,
so efficacious in intermittents, that they often-
times bring them to a close as it were by a single
blow. Should they even survive, their force is
much diminished. But, what is of the utmost
moment, the system is thus prepared for the use
of other remedies, which would have been ad-
ministered in vain, and even to the injury of the
patient, haul they not been preceded by the oper-
ation of emetics. A very material object, then,
in the exhibition of emetics is, to pave the way
for the safe and certain use of febrifuge reme-
dies.

It is a circumstance no less certain, that when
emetics are neglected, the disease is apt to be-
come stubborn ond tedious. In such a case it
can be successfully combatted only by emetic
medicines. This is an argument greatly in their
favour. I have learnt from innumerable experi-
ments, that there is no hope of a recovery with-
out copious vomiting. So efficacious has this
remedy appeared to me to be, that I have con-
sidered it practicable to prevent impending fevers
by its proper use. Nor, indeed, have I been de-
ceived in this opinion. I have kept many per-
sons free from intermittents, though strongly
inclined to them, by the repeated use of eme-
tics.

181

Young persons and adults arc alike benefited
by the operation of emetics. Nor is the use of
tartarized antimony to be considered as hazard-
ous to the former. Experience has taught me
that the action of that medicine is milder in chil-
dren than in persons further advanced in years.
Many times, however, to avoid alarming my pa-
tients or their friends, I have administered Ker-
mes mineral instead of it, and that with a happy
effect. In the case of a female child three years
old, who laboured under a tertian fever which
also at times assumed the quartan form, I remem-
ber to have used this latter remedy. As often as
vomiting was excited by it, so often did I obtain
for my patient a respite of eight or twelve days.
In this manner did the disease continue to the
great distress and eminent danger of the child,
from autumn throughout the winter, and even
to the following summer, when the powers of na-
ture and the change of the season effected a
cure.

But it is necessary that vomiting be excited
either by this or some other medicines. For if,
as sometimes happens, their action be directed
to the bowels so as to produce a purging, their
effect is not equally salutary. I have remarked
this in many cases of disease, but particularly in
a certain epidemic constitution, in which medi-
cines usually passed oft' by the bowels. From an

182

intestinal evacuation, however copious, the same
benefit was not derived, as commonly result-
ed from vomiting. In this case it appeared to
me that ipecacuanna was preferable to tartarized
antimony, because it produced with more cer-
tainty an evacuation of the stomach.

If it were requisite to confirm these things
by the authority of others, arguments might be
drawn from sundry medical writings. Vomiting
is necessary, says Celsus, in all cases where the
paroxysms are introduced by a coldness and a
shivering. Galen makes mention of many per-
sons being perfectly cured by vomiting alone.
Paulus and Aetius speak also in praise of eme-
tics. Some more modern writers attribute also
great efficacy to these medicines. Among these
Riverius extols them greatly : in his opinion
they are more certain and useful in their opera-
tion than any other remedy : he considers them
particularly beneficial when administered for
three mornings in succession. Such a practice
must not, however, be ventured on but with
great caution.

There are some physicians Mho fly to wild
spikenard, as the only sheet-anchor of safety in
protracted iniermittents. Others, according to
Jacotius, cure them with salt of vitriol. Some
have recourse, and that successfully, to the aqua

183

bencdlcta of Rulandus ; while others do not
shrink from the adoption of more powerful me-
dicines, such as red precipitate, and other pre-
parations of mercury. But the human mind is
so fluctuating and unsteady, that it cannot with-
out great difficulty be brought to rest at any
fixed point. Tossed on the uncertain tide of
opinion, it is constantly borne about in pursuit
of new discoveries. Hence it is that physicians
will neither tread in the footsteps of the ancients,
nor be led by the observations of others, to re-
peat the experiments on which those observa-
tions were founded.

CHAP. V.

Of the use of Purgatives.

1 WOULD not, however, be understood
to mean, that no intermittent can be cured with-
out the use of emetics. Many diseases of the
kind are removed or terminate of themselves
without any previous vomiting. Some of them
are too slight to stand in need of such a powerful
remedy. Besides, impediments sometimes oc-
cur which forbid the use of emetics. In many
cases, for instance, the stomach cannot bear
their irritating power. They are particularly
hurtful in affections of the lunsrs. Thev are also
hurtful to cachectic patients, who labour under
local affections of other parts. Finally, it would
be unreasonable and absurd to harass the sick
with emetics, on each return of long continued
intermittents.

185

But when this remedy cannot be called to
our aid, purgatives must by no means be omit-
ted. If the stomach only be evacuated by the
emetic, or the bowels, as often happens, be but
slightly moved, they must be solicited to fur-
ther discharges. Some practitioners, therefore,
are in the habit of employing emetics and cathar-
tics combined together. To me, however, it
would seem better to exhibit, first, some gentle
purgative, and afterwards when it has begun to
operate, to administer an emetic. In this way
both the desired effects are obtained. The
cleansing of the bowels by means of purgative
medicines is so necessary, that, unless it be pre-
viously attended to, other remedies are very fre-
quently employed to no purpose. This posi-
tion can be established by numerous argu-
ments.

It may be laid down as a general principle
that a plethora, of whatever kind it may be, is
hurtful in fevers. It is necessary, therefore, to
expel, as soon as practicable, all depraved and
putrid juices from the intestinal tube. This
cleansing of the alimentary canal is of the more
consequence, in as much as it relaxes the sur-
rounding parts, makes the blood circulate more
freely, and opens the secretory and excretory
ducts. In consequence of this relaxed state of
things, the bile, which acts an important part in

b b

186

intermittents, will pass off with more ease. The
urine also, the free secretion of which is of such
moment, will pass more copiously through the
kidneys.

Certain remedies, besides their purgative pow-
ers, are also possessed of other properties no less
useful. Many of these not only act on the intes-
tines, but are truly aperient; they stimulate
the liver for instance, and produce a flow of bile
from it. Thus, when that viscus is obstructed,
laxatives are prescribed, such as burdock- root,
vitriolated tartar, and arcanum duplicatum :
senna itself is also given at times in certain
doses, of the effects of which we have satisfacto-
ry evidence.

But to speak more particularly of intermit-
ting fevers, it is well known that they have been
cured by certain purgatives, and those not mild
and lubricating, but stimulating and acrid.
Scammony, hedge-hyssop, the powder of cor-
nachinus, the pills of sagapenum by Querceta-
nus, and theantimonial preparations of Bontius,
have been of service in many quartans. The
preparation of Riverius composed of calomel
and jalap has produced the same happy effects.
1 am acquainted with a popular or vulgar reme-
dy, which has cured vast numbers of people in
the country ; it is a powder composed of scam-

187

mony, turpith mineral, jalap, senna, cream of
tartar, rhubarb, cinnamon, and ginger. Simi-
lar effects have been produced by another reme-
dy of the same kind, devised by Hclvctius, and
since his time vended about as a secret. The
strength of this nostrum jesides in the gum
which it contains.

But whatever be the strength of these reme-
dies, it is best that they be not too acrid, else
they will prove injurious to those whose stomach
and bowels are tender and irritable. Besides,
milder remedies are sufficient for the cure of in-
termittents. In the mean time it is not sufficient
that they be administered once ; in various dis-
eases of the kind frequent recourse must be had
to them, in order to pave the way for a certain
cure. This is particularly necessary when there
is an accumulation of bile, when the intestines
are loaded with a collection of offensive and ill
digested humours, and, lastly, when the febrile
action is high.

An open habit of body is peculiarly necessary
in the course of the cure. It is certain that if
the discharge from the bowels goes on gently and
as it were spontaneously, and the bile be thus
drawn off, the fomes of the fever will be the more
readily eradicated. The truth of this is confirm-
ed by several of the phenomena of the disease.

188

There are many persons, for instance, to whom
febrifuge remedies had been exhibited for a long
time without any advantage : but while these re-
medies, when given alone, were useless or per-
haps hurtful, they oftentimes removed the fevers,
when laxatives were joined with them. After
the fevers are thus overcome, they are for the
most part ready to return again, in case a cos-
tive habit occurs. Nor can the evil be prevented
in any other way than by the exhibition of some
mild purgative joined to febrifuge remedies.

I know that the sentiments here advanced are
contrary to the opinions entertained by many
physicians, These consider it wrong to open
the bowels in the cure of intermittents. They
assert that, after the disease has terminated, it
will even return again, in case a purgative me-
dicine be administered. Experience is adduced
in confirmation c£the truth of this by many wri-
ters, and even Sydenham himself sanctions it by
his authority. But the circumstances which led
him and others to the adoption of this opinion,
are wholly unfounded.

It is certain that if at any time purgative
medicines, when used in the cure of intermit-
tents, have seemed to do mischief, the circum-
stance has been owing to some error. Either
some necessary preliminaries have been neglect-

189

ed, or the evacuation of bile itself has not been
attended to. When that fluid has begun to ac-
cumulate, evacuants too heating and irritating,
or such as evacuate but imperfectly, have been
administered. It may also have happened that
they were not joined with febrifuge remedies,
or that they were given in improper doses. No
wonder, then, that the fever appeared to increase.
But the fault lay in the physicians, not in the
purgatives.

As to those fevers which have terminated,
and which seem to be cured, their poison may,
as formerly mentioned, lie dormant for a long
time. It may even be silently accumulated,
and thus gather strength. If, when things are
in this state, the body be much disturbed by an
ill-timed purge, it is not to be wondered at, if
the fever which had lain in ambush, as it were,
ready to break forth, should suddenly and un-
expectedly make its appearance. The febrile
poison would not have acted thus, had it been
subdued; and had the purgative been admini-
stered with the necessary precaution,* it would
have eradicated the last relics of the poison. The
proper use of purgative medicines does not, then,
pave the way for relapses.

CHAP. VI.

Of the use of Aperients.

BUT although the necessity for purgatives
is great, it does not follow that no intermittent
can be cured without them. But we must direct
our attention to those occurrences and principles
which are most common, and not suffer our-
selves to be diverted from them by such as are
much less cqmmon. In general, therefore, as
we have already observed, it is absolutely necesr
sary to have recourse to purgatives in the cure
of inter mittents.

There are, in the mean time, cases in which
the evacuation of the intestines can be less rea-
dily dispensed with than in others. If, for in-
stance, the disease be of very long standing; if
the abdomen be tumid or hard; if the skin be
tinged with bile ; if the urine be thick or high
coloured; finally, if the habit be cachectic in

191

consequence of obstructions ; if, I say, any or
all of these circumstances exist, the medicines
called specific febrifuges are of no avail ; the
cure must not be attempted with them, until
the impediments be first removed by a discharge
of the vitiated humours.

But, for the complete discharge of these hu-
mours the evacuation of the bowels is not alone
sufficient. Impediments exist in many other
parts of the system, which must also be remov-
ed ; thus, the various secretory and excretory
passages or ducts must be opened; motion must
be restored to the stagnant fluids ; their fluidity
which is partially lost must be restored again,
and the bile must be recalled to its own proper
ducts, and to the cavity of the intestines. Re-
course must, therefore, be had to diluents, aperi-
ents, refrigerants, and saponaceous medicines,
and to these must be added some purgative me-
dicine, for the purpose of keeping the bowels
open.

The effects of the juices of herbs properly
prepared in removing obstructions of the abdo-
minal viscera are truly surprising. This may
be inferred from the influence of green herbs on
the bodies of horses, cattle, &c. These animals
are purged, and become lean in the spring ; their
fluids are made to circulate more freelv, and

192

their secretions are rendered more free and ac-,
tive. The same thing may be done by a phy-
sician, if to aperients and deobstruents he adds
a mild purgative just sufficient to move the
bowels.

What I have found best for unlocking the
passages of the liver is a purgative decoction or
beverage, made for the most part of wild bur-
dock, succory, hart's-tongue, and other herbs
of the kind. To this I have mostly added some
purgative salt, such as sal glauberii, or arcanum
duplicatum. This beverage will generally re-
move the obstructions unless they be uncom-
monly obstinate. It will never, however, prove
entirely efficacious, unless it move the bowels
two or three times a day.

These laxatives and aperients are necessary
not only in fevers of long standing, and in such
as are kept up by obstructions ; there are others
of recent origin in which the same remedies
ought to be used. Some fevers, for instance,
attack and run on with great violence ; in these
the viscera are parched with extreme heat ; the
liver is particularly affected ; the bile is of a deep
yellow or green colour, the feces are highly of-
fensive ; the urine is red or of a brick-dust co-
lour ; cases of disease where these symptoms
prevail resist common febrifuge remedies, and

193

unless recourse be had to such as open the pas-
sages of the body, the febrile poison cannot be
readily vanquished.

In cases of this kind, I have derived advan-
tage from putting my patients for a week or
longer on the use of aperients and laxatives.
To some of these I have prescribed the juice of
succory, borage, and bugloss, with sal glauberii,
or some other saline purgative ; to others a de-
coction or beverage prepared from the same or
some other herbs, with tartarum vitriolatum in
it ; and, lastly, cases have occurred to me in
which my patients derived the greatest benefit
from the use of whey. Whey is a liquid which
contains the juices of herbs, prepared and con-
cocted, as it were, in an animal laboratory. It
is also impregnated with a quantity of vegetable
salts, which sometimes operate actively as pur-
gatives.

This mode of treatment very seldom disap-
points our expectations. Such is the extent of
my confidence in it, that as often as I have met
with an obstinate case of intermitting fever, I
have had recourse to the foregoing, or such like
remedies. Of such remarkable efficacy have I
considered these remedies, that in many cases I
have not hesitated, after the exhibition of gene-
ral remedies, to continue some time in the use

c c

194

of aperients. In this way the system was the
better prepared for the action of febrifuge medi-
cines.

There is yet another remedy in which I
place great confidence, when the patients are
willing to submit to it. After their bowels are
sufficiently evacuated, I put them on a watery re-
gimen for three or four days. During that time,
I prohibit them from using any other kind of
drink or food. By thus drinking six or eight
pounds of water a day, the fever is almost entire-
ly removed. I consider warm water as the most
efficacious, yet cold water will answer in the
summer season. This method seldom fails of
success. It has succeeded with me in remov-
ing obstinate fevers, which had resisted every
other mode of treatment. If some relics of these
fevers still remained behind, they were easily
subdued, and that by gentle means. Is it not
surprising that we should ransack Asia and Ame-
rica for remedies, when more efficacious ones
are every where to be found

CHAP. VII.

At what time the remedies mentioned In the foregoing
chapters are to be administered*

IT remains to consider, at what time the
foregoing remedies are to be employed. Blood-
letting may be practised both during the pa-
roxysm and during the intermission. When
employed during the paroxysm, it is intended
to break the violence of the fever, and of its con-
comitant symptoms ; when during the inter-
mission, it is used as a prophylactic, to render
the succeeding fits lighter, and thus to pave the
way for other remedies.

These circumstances are so plain as scarcely
to require any directions. But such has been
the rashness of some men, that they have ven-
tured to open a vein during the cold fit. This
practice is unreasonable and hazardous. When

196

the pulse is so depressed as to be almost imper-
ceptible ; when the blood scarcely circulates ;
when the vital principle seems to be already
overpowered, what benefit is to be expected
from blood-letting ? Can it be had recourse to
without danger in old persons, as such are some-
times known to expire under the violence of the
cold lit ?

During the cold fit is a time equally im-
proper for the use of other evacuants. Those
in particular which act with force are hurtful.
Emetics, therefore, cannot be ventured on, al-
though the patients be affected with nausea and
vomiting. It is not in this as it is in that vomit-
ing which arises from a superabundance or an
acrimony of the humours. In the cold stage of
fever, the action of the stomach is inverted by
nervous irritation, and an affection of the liver.
That organ like all other parts of the system is
contracted. It does not, therefore, obey the
action of remedies as in a state of intermission
or health. These remedies can only produce
anxiety and very distressing pains, without being-
able to excite any discharge from the constrict-
ed vessels of the viscera.

It must be confessed, however, that even un-
der such circumstances, emetics do sometimes
succeed. Vomiting, says Riverius, excited at

197

the commencement of a paroxysm renders it
milder and shorter. There was lately an Eng-
lish physician, who, during a practice of twenty
years continuance, was in the habit of giving an
emetic at the commencement of the cold fit. In
case excessive tremors forbade this, he usually
administered it at the commencement of the hot
fit. Somewhat similar to this was the practice
of Asclepiades. Celsus more judiciously exhi-
bited only tepid water slightly impregnated with
salt, for the purpose of exciting vomiting. Not-
withstanding these circumstances, any inverted
action of the stomach, unless produced by warm
water alone, is to be dreaded.

Sydenham with more propriety timed his
emetic so, that its operation might be terminated
previously to the access of the paroxysm. So
far was he from believing that a tumult excited
in the viscera at the beginning of the fever could
be beneficial, that he recommended to his pa-
tients a gentle anodyne after the operation of
the emetic, and immediately before the attack of
the paroxysm. Both, however, had better be
omitted.

Some practitioners have, with equal indiscre-
tion, administered purgatives during the cold
stage, or, what is still hurtful, at the very com-
mencement of the hot stage. They did not, or

198

Would not see, that when the system is constrict-
ed in every part with cold, or agitated by heat
and motion, the bowels cannot well be opened,
and that the application of irritants must excite
the greatest commotions. ' Those physicians
have acted with more prudence and discretion,
who have exhibited such medicines previously
to the commencement of the paroxysm. In-
stead of four hours before this commencement,
as some writers direct, the purgative medicine
should be given six or eight hours before it.
This is the way to render it useful, as appears
from various examples. Some physicians have
known the disease to be removed by administer-
ing cornachinus in powder, a certain time pre-
viously to the paroxysm.

So averse have the more skilful physicians
been from the use of purgatives, in the cold stage
of fever, that they have, on the other hand, used
remedies of a heating nature. Some of these
have given three, six, and even twelve grains of
pepper : others have had recourse to theriaca,
and assert that by these means the fever was re-
moved. Others again have prescribed heating
substances and febrifuges combined, and that
with the same degree of success. Nor, indeed,
does this practice appear, at first sight, so con-
trary to reason as does the use of purgatives and
emetics during the cold stage. When the whole

199

system is affected with cold and shivering, heat-
ing substances would seem rather useful; but
they are, notwithstanding, to be rejected. They
generally augment the violence of the fever. If,
however, the vital principle seem to flag, and
the violence of the cold stage be extreme, it is
admissible to have recourse to some gentle
cordials.

I The body, therefore, is not only not to be purg-
ed, nor stimulated by heating medicines, during
the cold stage of fever; but, on the other hand, it
ought not to be disturbed at all ; tepid water
alone, or mixed with some gentle cardiac should
be taken in. Nor ought the system to be in any
measure agitated, during the succeeding hot fit.
All heating substances and purgatives will be
hurtful. Acid, or acescent drinks are better
calculated for moderating the febrile heat. Even
water alone will suffice, particularly when the
sweat begins to flow. Thus, the fluid which
passes off by the skin, is restored by the mouth,
and the grosser humours are sufficiently diluted.
That the aqueous drinks, however, may be the
better mixed with the blood, let some syrup be
added, such as syrup of violets, syrup of cit-
ron-peel, or let some Rhenish wine* be given

* The propriety of adding wine, or any oilier highly stimulating
liquid to the drinks of patients in the sweating stage of intermitting
fever, is, at best, problematical. I ought rather to have said, that

200

to prevent the sick from being too much ex-
hausted. In this way will the sweats be pro-
perly regulated; for if they be too profuse,
they will prove hurtful; the fever will become
worse, and may even assume a continued form.

As to aperients, it is scarcely necessary to
give any directions respecting their use. Pro-
vided they be lenient, they may be given at any
time. Vegetable ptisans holding nitre in solu-
tion, and lemonade, are highly useful during the
continuance of the fever ; so, likewise, are weak
infusions of borage, bugloss, and other bever-
ages of the kind. But those articles which arc
possessed of much activity, and which are in-
tended for the removal of obstructions, ought
not to be used before the termination of the pa-
roxysm ; indeed their exhibition must even be
deferred till the primas viae be cleansed by
emetics or purgatives. This precept ought to
be attended to, at least in the commencement of
fevers. But when they are of long standing, or
when the sick have relapsed into them, as their
character is changed, a change must also take
place in the method of exhibiting the remedies.
But this subject will be considered in a subser
quent chapter.

the practice is hazardms and should not be adopted. On such oc-
casions, mild, diluting drinks are all that are, in general, either ne-
cessary or admissible Trans.

CHAP. VIII.

Of the various methods of curing fevers , and first, of
the cure by means of sudor ifics.

ALTHOUGH the remedies already men-
tioned, possess great power, they only pave the
way for a cure. We pass on, therefore, to the
consideration of others, which have a more par-
ticular or specific relation to intermitting fever.
There are two methods in which the cure of this
disease may be attempted. The first consists in
endeavouring to prevent the occurrence of the
cold fit by mild sudor ifics. To enable the
reader to judge the more correctly of these re-
medies, or their effects, we will premise a few
remarks, founded on observation and experi-
ence.

Previously to the sick being seized by the
cold fit, half an hour for instance before the im-

DCI

202

mediate attack, all the functions of the system go
on, at times, without any disorder. The patient
does not seem to be at all infected by a febrile
poison ; nor does he experience any sensation
to warn him of the approaching paroxysm. To
produce the paroxysm, then, the poison must
burst into a blaze, as if fire were applied to it.
But cannot this flame be prevented, or, which
amounts to the same thing, while the poison is
yet inactive, can it not be smothered so as to
prevent it from breaking out in the form of a
cold fit or fever ?

Such a project certainly does not appear un-
reasonable. On the other hand it seems highly
probable, that if a sweat be excited before the at-
tack of the cold fit, it will be entirely prevented.
But, in case of its prevention, there will be no
congestion or stagnation in the liver, the auricles
of the heart, or the lungs. Besides, it would
seem that part, at least, of the febrile poison may
be dissipated. Thus, if the skin be constricted,
the more gross fluids are accumulated in its ves-
sels and excretory tubes; if in this state of things,
a very copious sweat breaks out, the obstruc-
tion will be removed through the cutaneous
pores. But the same thing will occur with re-
spect to the state of the viscera, when a febrile
paroxysm is impending. Therefore the febrile

203

cause if not entirely removed, will be at least
greatly weakened.

But in medicine, all reasoning is uncertain,
unless confirmed by experience. Even experi-
ence itself, teaches us many things that do not
precisely accord with what is here laid down. It
is certain, indeed, as already mentioned, that
those sweats which follow the paroxysms do not
always check the febrile action. Yet those fe-
vers where no sweats occur, generally continue
longer, and rage with more violence. Those
physicians, however, who, with a view to pre-
vent a paroxysm, endeavour to force a sweat by
great external heat, or who administer for the
same purpose a heating decoction of guaia-
cum or sassafras, generally render the disease
worse.

From these considerations, however, no well
founded arguments can be drawn against all
kinds of sweats. Those sweats, for instance,
which succeed the paroxysms are morbid, or
constitute in reality, a part of the disease; for
they frequently occur while the bowels are still
parched with the febrile heat. It is, therefore,
in intermitting fever, as it is in eruptive fevers;
sweats oftentimes flow copiously without afford-
ing any material relief to the sick. In both
cases, the more fluid parts are thrown on the

204

surface of the body by the febrile action, while
the fomes of the disease still remains within.

With respect to sweats excited by too much
external heat, or by the force of heating reme-
dies, they are wholly unfavourable to the cure
of fevers. Thus, the stimulus of guaiacum is
too acrid, and excites by far too great a degree
of heat in the bowels. So hurtful, at times, are
the effects of that medicine, that I have seen
cases of jaundice produced by it. But whatever
thus disorders the functions of the viscera, even
although it produce the most copious sweats,
cannot be a remedy for fever. Let it be laid
down then, as a principle, in the cure of fevers,
that the body must not be overheated. The
force of the disease is necessarily increased, if
the heat in the viscera be increased.

Those sweats, therefore, are most beneficial
which are not forced from unwilling nature, but
which flow at the proper time and in a gentle
manner. To procure such sweats, the follow-
ing circumstances must be attended to. First,
too much heat must not be excited : Secondly,
aperients should be always mixed with sudori-
fics : Thirdly, in certain affections of the liver,
or of the other viscera, they must not be exhibit-
ed any more than they must in the highest suite
of cachexy : Fourthly, and lastly, where there

205

is a turgid state of the blood-vessels, or when
the stomach is loaded with vitiated humours, a
cure by means of sweating must not be at-
tempted.

These things being attended to, and the ne-
cessary general remedies being premised, that
method will be most salutary and safe, which
attempts the cure of intermittents by sudorifics.
Yet these remedies will be more useful in the
beginning than in an advanced stage of those
diseases.

CHAP. IX.

Of the mode of exhibiting sudor ifics in the cure of
fevers.

AFTER having premised the foregoing ge-
neral rules, it would seem scarcely requisite to
give any particular directions on the subject.
But to close up every avenue throughvvhich error
might find an entrance, we will specify the time
most suitable for these remedies ; we will then
point out the remedies to be selected as most
useful ; and, lastly, describe the method to
be observed in their exhibition. After hav-
ing gone through these several heads, we will
endeavour to make it appear how far this method
of cure is to be relied on.

As to the time, the patient must be allowed
a sufficient degree of rest to refresh his system,
agitated by the fever and debilitated by the pro-
fuse sweat. But as soon as practicable, it will

207

be proper to have recourse to the sweating plan.
Yet experience has oftentimes taught me that it
will be sufficient to prevent the cold fit, if the
medicine be exhibited three or four hours be-
fore its access : but if given at a later period, it
will be either useless or very nearly so : the hu-
mours of the body cannot then become suffici-
ently impregnated with it, and they consequent-
ly, will not be prepared to pass off by the pores
of the skin.

Those remedies which appear to me to ac-
complish the object in view most safely and
certainly, are certain medical substances, endu-
ed with penetrating yet mild qualities. The
principal of these are sarsaparilla, burdock, bit-
ter-sweet, and male speedwell, all of them ape-
rient remedies. I am well persuaded that other
remedies would effect the same purpose, but I
am here laying before the reader the result of my
own experience only. I do not consider it ne-
cessary that all these articles should be prescribed
at the same time ; I have sometimes exhibited
one or another of them singly, with great advan-
tage, and that in the cases of many sick persons.
I will adduce one very memorable example in
confirmation of this.

An old man, aged eighty, had experienced
two paroxysms of a quartan fever. So violent

208

had the cold fit been, that he was threatened with
certain death in case of another attack similar to
the two former ones. Deeply affected at this
melancholy prospect, I prefered a sudorific me-
dicine to all others. I therefore exhibited a de-
coction of sarsaparilla and burdock with sal
ammoniac. By this remedy the cold fit and
paroxysm were prevented, nor did any vestige
of the fever remain behind. Perhaps this cure
might, by some, be attributed to the sal ammo-
niac. But the decoction has at other times suc-
ceeded equally well with me, without the addition
of that salt.

In the mean time the mode of administering
this remedy, may contribute much to its force
and efficacy. The decoction must be drank
not sparingly, but in large quantities. Five or
six pounds of it, for instance, ought to be used
on every day of intermission, with this precau-
tion, that previously to the time of the occurrence
of the fever, the patient compose himself in bed.
These previous steps being taken, the sweat
will be brought on the more readily, if the plen-
tiful use of the diaphoretic decoction be still con-
tinued. Nor must this remedy be laid aside,
even when the body begins to be covered with
moisture, but should be persevered for several
hours.

209

However Wife this administration of sudori-
fics may appear, I \\i\\ v been sometimes appre-
hensive of exciting too much heat by it. To
prevent this, it appears advisable to prescribe,
immediately after the remission of the fever, a
warm infusion of borage or bugloss, which will
be rendered the more cooling by the addition of
a moderate dose of nitre.

What has established in my mind the utility
of this mode of exciting a sweat, is a common
and therefore a valuable remedy, of which I have
had some experience. When I have been desi-
rous of employing more lenient sudorifics, I
have tried the efficacy of warm water. I have
directed, for instance, a large quantity of this to
be drunk a few hours before the paroxysm. Con-
trary, in some measure, to what I was prepared
to expect, the cold fit was prevented as if by a
charm. This result I have witnessed not only
once, but frequently, nor indeed have repeated
experiments which I have made, left in my mind
any doubt as to its reality.

But whatever may be thought respecting

these particular medicines, it is certain that the

method of removing intermittent by sudorifics,

is in various cases absolutely necessary. This

method must be had recourse to, if the cold fit be

violent, and dangerous ; indeed there is no other

e e

210

way in which the cold fit can be counteracted. I
would not, however, assert that this method
eradicates the fever so perfectly, as to render it
unnecessary to have recourse to any other reme-
dies to complete and confirm the cure. Perhaps
the effects of the febrile poison are only kept
down by sudorifics, while the poison itself still
lurks in the system, and silently pervades all its
parts. Those who have been relieved from in-
intermitting fevers, cannot, therefore, be per-
fectly safe, unless the poison has been thoroughly
eradicated by specifics : this, at least, is in ge-
neral the case.

CHAP. X.

Of attempting the cure of fevers by specific medicines :
and first, an inquiry what these specifics are, and
whether or not, any emetics or cathartics are to be
considered as such.

THERE is, therefore, a more safe and cer-
tain method for the removal of fevers, namely,
that which consists in curing them by peculiar,
appropriate, or specific remedies. Medicines
of this kind, have been earnestly sought for in
every age, and many practitioners have suffered
themselves to be persuaded, that such were actu-
ally found, when in fact they were still wanting.
Physicians, however, left nothing untried in this
inquiry. We have already treated of emetics
and purgatives : in these remedies certain phy-
sicians, and those not of inferior reputation, have
reposed unlimited confidence. Some select me-
dicines of this class have even been vended about
as secret nostrums.

212

We have already said, that emetics and pur-
gatives do much towards the cure of intermit-
tents, but that they do this only by paving the
way for other remedies. Since, indeed, such is
the nature of intermitting fevers, that they may
sometimes be removed by a shock, or a sudden
change in the natural movements of the system,
it may so happen, that they may be cured by the
action of emetics or purgatives. Besides, such
may be the state of the body, that, after the eva-
cuation of the stomach and intestines, the func-
tions of the several parts may be restored to
health. Finally, the febrile poison may be eli-
minated by a kind of crisis, and, as it -were, by
a single exertion. But this success is only ac-
cidental. These are not the proper remedies for
intermittents, nor are they calculated to over-
come the febrile cause of themselves.

But although these remarks are true in eene-

ral, I would not have them considered as ap-
plicable to all medicines of the kind. There may
be in some medical articles which excite vomit-
ing and purging a power peculiarly febrifuge.
No doubt but this may be the case with respect
to Riverius's remedy for quartans. The precise
nature of that preparation is not known, but
•it appears to contain both mercury and antimo.
riy in its composition.

213

I am also acquainted with a vegetable sub-
stance of a purgative nature, long celebrated in
this country as a febrifuge, and which is even
purchased up at a considerable price. It is the
cuticle or external covering of the sea-lettuce.
This, when dried before a gentle fire, and re-
duced to a powder, is exhibited in doses of a
scruple, and continued in this manner for seve-
ral successive days. Some practitioners have
prefered giving it infused in niuk.

There is another milder purgative, which
was formcly a secret nostrum, namely, cream
of tartar, exhibited frequently in doses of an
ounce. This article is at once cooling, purga-
tive, and antiseptic ; whence in the commence-
ment of fevers, it appears to me to be a remedy
not to be slighted. The same thing may be said
of the nostrum of Mynsichtus,* which has
oftentimes cured intermittents when other reme-
dies had failed. I have myself prescribed that
remedy sometimes with the happiest effects. It
is cooling, purgative, and aperient, and is pe-
culiarly calculated for correcting bile, and re-
moving hepatic obstructions. Hence it is en-
titled to a respectable rank among febrifuge
remedies.

* The formula of this nortfUlB i-> not inen*iom\i by our tfuthov,

Trans.

214

Equally to be esteemed is the febrifuge of
Riverius, which is composed of vegetable alkali
and sulphuric acid. From the union of these
two articles arises a salt* not dissimilar to that
which constitutes the foregoing nostrum of Myn-
sichtus, as appears from a chemical examination
of it. But I have ascribed very different virtues
to magnesia alba, which some practitioners use
as a febrifuge. This, however, is not always
alike efficacious. It is sometimes, however,
when mixed with cream of tartar, prescribed
with happy effects. I once knew a physician
who used an infusion of it in wine as a purga-
tive.

But although remedies of this kind do at
times much good, we must not in most inter-
mittents trust to them alone. They very fre-
quently disappoint us, or produce only a tem-
porary suspension of the disease. It is of great
importance, however, to be acquainted with
them, in order that they may be joined with ac-
tive febrifuges, or substituted occasionally in
place of them. There are certain temperaments,
and certain irregular fevers, to which remedies
of this kind are best suited. The physician,
therefore, must be supplied with such a stock
of remedies, as will enable him to accommodate
his practice to different cases.

* Sulphate of poUish.

CHAP. XI.

Whether or not a true febrifuge power reside in certain
sudor if its, bitters, aperients, and other remedies.

WE have already treated of sudorifics and
the mode of administering them. These cannot
be considered as true febrifuge remedies, if
they only excite sweat. To deserve to be ac-
counted antidotes to intermitting fever, it is ne-
cessary that they should possess a certain peculiar
or specific power. In theriaca no such power
resides, although it was attributed to it by the
ancients. How far such a remedy is to be trust-
ed, appears from Galen himself. That writer
remarks, that by the exhibition of it, a simple
quartan was converted into a double and even a
triple one. He mentions the same thing as hav-
ing happened to Eudemus the philosopher. It
is to be lamented that encomiums are frequently
bestowed on medicines of this description, which
are not only useless, but even hurtful.

216

Physicians have had recourse to other reme-
dies, better calculated for the cure of fevers
Even the ancients themselves, suspected the
existence of a febrifuge power in bitters. They
therefore, made trial of gentian, germander, the
lesser centaury, and a species of trefoil, and that
oftentimes with happy effects. They have spoken
highly of the lesser centaury in particular ; but I
have observed it to excite very great heat, and
not unfrequently to increase the violence of the
fever. Yet it cannot be denied, but that, when
added to the peruvian bark, it has been some-
times of great service ; for it has subdued fevers
which had resisted other remedies. It is said,
that if the system being first properly prepared
for it, a decoction of it be given combined with
laudanum, it will be productive of still better
effects. The same thing is said respecting an
infusion of the flowers of broom.

Respecting other bitters, I can say nothing.
Their effects are uncertain, sometimes even hurt-
ful. Thus gentian is not undeservedly blamed
on this score, in 'as much as its bitterness is
acrid, and apt to excite heat. What appears no
less foreign from the cure of fever, many of them
have astringent as well as febrifuge properties.
Some practitioners have exhibited alum, others
plantain and cinquefoil. Alum certainly pos-
sesses some degree of anti- febrile power; for

217

patients have taken it dissolved in water with
advantage. Many have declared plantain to be
possessed of the same power, and have exhibit-
ed it either immediately before, or about two
hours before, the accession of the paroxysm. I
have indeed known obstinate fevers removed by
a beverage in which the leaves of this herb had
been boiled. Cinquefoil has in the mean time
succeeded still better, as also the bark of the
root of the wild plum-tree. Still, however,
these remedies ought not in my opinion to be
often used ; for when they constrict parts that
contain the febrile poison, it is apt to remain in
them at a greater depth, and with more per-
manence.

With more justice are praises bestowed
on certain articles possessed of a penetrating
power, such as aperients, and saponaceous sub-
stances. Among these, burdock holds a con-
spicuous place, while it is at the same time a
sudorific. By this remedy Henry III. king of
France, is said to have been cured of a quartan
fever. Many other similar instances are men-
tioned, The herb, speedwell, possesses the
same power in an equal degree, according to
Cesalpinus, who was a most able and accurate
judge of these things. Finally, of the same effi-
cacy and value is the juice of the rape-root,
which is so highly extolled bv Crato. Notwith-

standing what has been said, daily experience
teaches us that we must not rely on these reme-
dies, as true febrifuges. Although they have
cured some, they have failed in the cure of many
more.

It appears to me that more confidence is to
be placed in the aperient salts, of which we have
already treated, or in the febrifuge salt of Sylvius,
to which physicians, and even the author him-
self, have given a higher character than it de-
serves. Purging salts, have, indeed, at the same
time a febrifuge power, but this power does not
always act with certainty ; to these, therefore, sal
ammoniac is to be greatly preferred. This reme-
dy, indeed, possesses great efficacy in the remov-
al of fevers which are even highly obstinate.
Hence, at times, when other remedies prove in-
effectual, we are forced to have recourse to that
salt.

Finally, the effects of the salts of Tachenius
must be referred to an aperient and penetrat-
ing power. The virtues of the plants from which
they are extracted cannot still remain in them ;
for their principles are changed by the action of
the fire. They are partly alkalescent, and con-
tain also a portion of thick oil; whence, being
of a saponaceous nature, they are extremely
well calculated for the removal of obstructions.

219

But it is not alkaline salts alone, certain
earths also possess qualities calculated for the re-
moval of intermitting fever. Thus, burnt egg-
shells are exhibited with happy effects in that
disease. The truth of this is established by
many experiments detailed in medical writings.
To these earths vegetable alkali is sometimes
added, and I once knew a physician who used
a mixture of these two articles with very flatter-
ing success. These earths first calcined and
then mixed with salt of tartar, have been used
by Riverius in various cases of disease. The
mixture was usually dissolved in simple water,
and given to the sick in solution. I have, my-
self, sometimes used this remedy with success
in obstinate quartans. I would not, however,
recommend it to general use, as it seems to b$
possessed of too much acrimony.

There are other remedies, and those some-
times of opposite qualities, which physicians use
in practice, such as aromatic antiseptics, which
stimulate the system, and narcotics, which act as
sedatives. Of the class of stimulants, I shall treat
of only two, the efficacy of which is worthy of no-
tice. The ancients themselves spoke in the highest
■terms of worm-wood, which has been also used
with success by a late Italian physician. Cha-
momile is spoken of as no less efficacious by a
physician of Portugal, and Morton considers its

220

flowers as highly useful. But if these vegetables
do possess febrifuge virtues, a circumstance
which cannot be denied, it must, notwithstand-
ing, be confessed that they more frequently dis-
appoint our expectations, and even excite a
pungent heat, which is very unfavourable to the
cure of fevers.

As to narcotics, we must acknowledge with
Riverius, that they possess some efficacy in pre-
venting the paroxysms of fevers. Trallian used
opium, which, combined with castor and some
other articles, he exhibited two hours before the
fit as a certain remedy. Heurnius recommends
the same, combined with some other medicines,
in terms equally strong. I knew a physician
who was in the habit of exhibiting it in combina-
tion with camphor, with the happiest effects. I
have no doubt but opium combined with saffron
would be efficacious in removing the cause of fe-
ver. Both of these articles possess some febri-
fuge virtues, besides, that saffron is gently ape-
rient. They ought, however, to be taken with
caution.

Finally, that nothing might be left untried,
some physicians have had recourse even to poi-
sons themselves. They have exhibited arsenic,
and have succeeded with it in the removal of
many intermittents. Some of the patients,

221

however, thus cured, have afterwards died of
phthisis. There is a certain vegetable poison,
namely, the bean of St. Ignatius, which is less
deleterious. I was acquainted with a man who
was in the habit of exhibiting it to people in the
country with the greatest success. There is al-
so a remedy used by great numbers in this city,
and that not without success. Its efficacy de-
pends on its being composed in part of the bean
of St. Ignatius, an article which most people
dread, and which physicians condemn as a poi-
son.

Inunctions and external applications to the
wrists are more in use among the common peo-
ple than among physicians. Inunctions and
frictions along the spine were first instituted to
remove the sensation of coldness, which is usu-
ally experienced in that part. There is no
doubt, indeed, but the friction and motion, as
well as the power of the medicine with which the
sick are anointed, may sometimes be of service.
These remedies, however, are not to be confi-
ded in, nor ought their application, indeed, to
be opposed, in case any person believing in their
efficacy, wishes to use them.

As to applications to the wrists, if any re-
lief be derived from them, it is not to be con-
sidered as depending on any power specifically

222

febrifuge. Certain cures, which are truly sur-
prising, are rather to be attributed to motion
excited in the whole or a part of the body by
the application of a stimulus. There are cer-
tain unguents, for instance, which, if rubbed on
a particular part of the body, will produce erup-
tions in various other parts, and even excite mo-
tions in the viscera themselves. The same, or
something similar happens in the use of epicar-
pia, or applications to the wrists. If the ranun-
culus of the meadows be applied to the hands
and wrists, heat, pain, and excoriation are the
consequences. By the force of this stimulus,
and the effluvia making their way to the internal
parts, the fever may be eradicated so as not to
revive again.

We must not, however, imagine that fevers
can be removed by external applications, which
possess no stimulant power. Although the ef-
fects of such remedies are extolled by writers of
high respectability, they are, notwithstanding,
very doubtful. If there be any truth in the
praises bestowed on them, their efficacy arises
from the power of certain subtle effluvia, which
make their way into the internal parts of the sys-
tem. But let those persons believe in the effi-
cacy of such remedies, who have had satisfactory
proofs of it.

chap. xii.

Of the cure by means of the peruvian bar/:.

THE foregoing remedies, not very certain,
and sometimes, not very safe in their operation,
were succeeded by the peruvian bark. This
divine discovery was unknown to our ancestors.
Nor did our own age come willingly into the use
of it. A few physicians were its advocates, but
many suspected it of some deleterious qualities.
But uniform and successful experience over-
came at length their obstinacy and their fears.

I do not mean, however, to insinuate, that
all controversies and complaints on this subject
are terminated. There are countries in which
this celebrated remedy is still in bad repute
Among the Dutch and the Germans, the com-
mon people reject it entirely. But all the charges
which they bring against it, are to be attributed

224

to an improper method of using it. Among
the Spanish, the French, and the English, it is
no longer held in suspicion. Its use is sanction-
ed by general approbation.

So efficacious and innocent is it, that among
all the sick persons to whom I have ever pre-
scribed it, I have heard no well-founded com-
plaints respecting it. It not only suspends the
fever for a time, but, if the system be properly
prepared, eradicates it entirely. It is in the high-
est degree friendly to the stomach, promotes
perspiration, acts favourably on the blood and
nervous system, and is a powerful antiseptic in
the prima? viae. But as the mode of using it
ought to be accommodated to various tempera-
ments, and various descriptions of fever, there
are several preparations of it, with which it is
necessary to be acquainted*

Some physicians employ this medicine in the
form of an extract, others of a decoction, others
of an aqueous infusion, and others again of a spi-
rituous tincture.

But that the febrifuge virtues may be the bet-
ter extracted, physicians have recourse to ano-
ther menstruum more suitable for the purpose.
The bark, for instance, is infused in some gene-
rous wine for the space of twenty-four hours, cr

225

it is exhibited in powder in a glass of that liquid.
In this latter case the extract is made in the sto-
mach itself. When the extract is thus prepared,
a\ hcther within or without the body, it is a reme-
dy of a very active and penetrating nature. It
differs greatly in its powers both from wine and
spirits, in consequence of the gummy and resi-
nous principles of the bitter febrifuge which it
contains.

As to the efficacy of the remedy thus pre-
pared, it cannot be denied that it has been beni-
ficial to many. I can, myself, from experience,
bear witness to its activity; but its strength and
utility are increased, by adding to it some spirits
of wine ; whence it would appear that the febri-
fuge virtue of the bark resides principally in its
resinous. part ; for it is best extracted by a spiri-
tuous menstruum. A remedy so heating as this
preparation is, ought, however, to be given with
caution, else it may at times prove hurtful.

When the bark alone in whatever way it may
be administered, appears to be insufficient to
remove certain intermittents, physicians have
added many things to it as auxiliaries. Some, to
increase its efficacy, have mixed aromatics with
it, such as Virginian snake-root: others, for the
same purpose, have added certain febrifuge me-
dicines to it, particularly bitters : many have

226

joined aperients with it, that it might thus gain
access the more readily to the internal recesses
of the system: finally, a very considerable num-
ber have, for the accomplishment of the same
end, called to its aid certain salts which are pos-
sessed of a searching or penetrating power, such
as salt of wormwood, and sal ammoniac, the
latter of which is itself, as we have already men-
tioned, highly useful in obstinate intermittents.

Of all these and many other remedies it is
not my intention to treat at large. I shall, ne-
vertheless speak of two or three of them, which
are certainly capable of being highly useful. If,
in some obstinate cases of intermittents, the
lesser centaury be added to the peruvian bark,
it may prove a very efficacious remedy. It ap-
pears that the flesh of the viper dried, reduced to
powder, and exhibited with the bark, has been
equally effectual. By these mixed remedies many
persons have been relieved from intermittents,
after having tried all other medicines in vain.
But the following remedy which is purchased
at a very considerable price, seems to contain
the virtues of both the foregoing : viz. Take,

Of peruvian bark, two drachms.

Of millipedes, powdered, one drachm.

Of lesser centaury, do one drachm.

Let this mixture be infused in eight ounces
of generous wine, and given to the patient in

227

bed. At other times the powders are given in
honey in the form of an electuary.

But very often the primae viae are loaded
with vitiated humours, which may serve to keep
up the fever. Purgatives are, therefore, in par-
ticular, added to the bark. The bark itself, in-
deed, purges many persons, but, a circumstance
which is peculiar to it, it considerably increases
the action of other purgatives; hence small doses
of them only need be added to this febrifuge. By
some physicians a species of the lily, and also
the agaric have been used as remedies. The
latter article enters into the composition of one
of our nostrums, which proves oftentimes effi-
cacious. I have, myself, known it to be exhibit-
ed with advantage, to many people in the coun-
try. This remedy, however, should be admini-
stered with great caution, on account of the heat
or feverish action, which is apt to be excited by
the irritating quality of the agaric. Persons of
tender and irritable viscera ought to reject it al-
together.

Some physicians are in the habit of exhibit-
ing peruvian bark, mixed with stronger purga-
tives, such as puhis cornachini, or jalap ; nor
can it, indeed, be denied, that this composi-
tion has been sometimes found useful. It is,
in general, however, better to give the bark in

228

combination with such closes of arcanum dupli-
catum, or vitriolated tartar, as may serve to keep
the bowels moderately open. I have been in the
habit of administering the pulvis Stablii in com-
bination with the bark with singular advantage.

But my favourite remedy is, a febrifuge and
purgative decoction prepared in the following
manner. Take of peruvian bark, coarsely pow-
dered, an ounce, or an ounce and an half; boil
it in two pounds and an half of water to two
pounds ; towards the end of the process, add of
the leaves of senna, half a drachm, and of the
leaves of the borage and bugloss, of each, half a
handful. Instead of the senna, I oftentimes use
some purgative and aperient salt, such as epsom
salt, or sal polychrest, to the amount of four
drachms. This preparation, consisting as it
does, of purgative, cooling, aperient, and febri-
fuge articles, is calculated to answer every indi-
cation that can occur in the treatment of com-
mon intermittents.

CHAP. XIII.

Of injurious effects produced by the peruvian bark.

BY the mixture of all these articles with the
peruvian bark, its efficacy has appeared to some
physicians to be diminishedrather than increased.
By the bark alone, say these characters, vast
numbers have been and still are cured. There
are places in which intermittents are endemic ;
yet most persons who are attacked by them, use
scarcely any thing for their removal, but the
bark alone. Nor, if we may give credit to re-
port on the subject, was any other remedy ne-
cessary in those times when the bark was first
introduced into practice. At that period, in-
deed, this article was of better quality than at
present, and not liable to be fraudulently mixed
with other substances. Some physicians assert,
that if it be carefully selected even now, it will
certainly cure intermittents, when given even in

230

a moderate dose, and that without any medicines
either preceding it, or being joined with it.

But these instances must not be considered
as universal. The bark if exhibited alone, may
be oftentimes hurtful. It is bitter, astringent,
tonic, and aromatic. If given, therefore, in cer-
tain cases or temperaments, it excites heat, pro-
duces dryness over the whole skin, injures the
stomach, sometimes occasions pains in it, af-
fects the lungs, and extends its unfavourable in-
fluence even to the blood itself.

But this remedy may produce no less injury
in other parts of the system. In some cases,
after it has removed the fever, pains still remain
in the hypochondriac regions. It frequently at-
tacks even the spleen itself. That viscus, as we
have already mentioned, becomes enlarged, and
even inclines to suppuration. But I have learnt
from experience, that this affection is to be at-
tributed to peruvian bark as frequently as to the
fever itself.

Another objection against this remedy is,
that it is not always certain in its effects. Many
fevers, and those really intermittents, cannot be
cured by it. Even when it appears to succeed,
it not unfrequently happens, that it only sus-
pends the disease for a certain time. Many pa-

231

tients worn out, as it were, by this remedy, and
by an irregular fever, have dragged on a misera-
ble existence during the autumn and winter.
Peruvian bark alone, therefore, has been con-
sidered as nothing but a palliative remedy, and
is accounted only such by some physicians even
at the present day.

But a more weighty objection is, that this re-
medy oftentimes suffers the febrile poison to re-
main in the system in a latent state. We see
many persons who, after the removal of the fe-
ver, languish under a pale, tumid, yellow coun-
tenance, an enlarged abdomen, and anasarca of
the legs and other parts of the system ; they ap-
pear to have only exchanged their original dis-
ease for a secondary one that is much more dan-
gerous : for there are many who recover from it
with difficulty, or at least not till after a tedious
lapse of time.

We meet with others who experience cer-
tain anxieties or uneasinesses at those times at
which the paroxysms had usually occurred.
Others again fall into a deep sleep, or stupor,
about the same hour. Some, having the cause
of the disease directed to other parts of the
system, are attacked by a diarrhoea or dysentery.
Finally, sometimes when the fever is checked,
wandering spasms occur in place of the regular

paroxysms, and excruciating pains at the same
time attack the limbs, bowels, breast and
head.

From the very cure of the fevers, then, an
argument of some weight arises against the effi-
cacy of the bark alone. When the preceding
symptoms assume the place of the regular pa-
roxysms, a renewal of the fever, as we have al-
ready observed, becomes sometimes necessary
for their removal ; for it has been remarked that
they disappear on its return, and vice versa.
Some physicians, on discovering this, have
sought not for a febrifuge remedy, but for one
calculated to recall fever ; and they declare that
they have found spirits of sal ammoniac to be
possessed of that property.

From these circumstances it appears, that
the peruvian bark is calculated to restrain the
effects of the febrile poison, rather than to de-
stroy the poison itself. For the poison may in
fact remain sound and untouched, as it were,
even after the paroxysms have disappeared.

No wonder then that some physicians de-
cline considering this remedy as a true antidote
to intermitting fever. For, besides the restrain-
ing of the paroxysms, which may be accom-
plishedby other remedies, such as astringents

233

and bitters, it is further necessary that the fe-
brile poison be altered in its nature or expelled;
but this expulsion is effected either by the natu-
ral action of the system, the force of the pa-
roxysms, or by other auxiliary remedies which
do not possess any true febrifuge power.

But if by the peruvian bark the occurrence
of paroxysms may be prevented, by an improper
and unskilful use of that remedy, simple inter-
mittents may be changed into continued fevers,
double tertians or quartans. And if such a
change even be not actually effected, still the fe-
brile heat may be increased, all the symptoms
may be rendered worse, and their cause may be
made to take deep root. Hence the disease will,
with more difficulty, yield to remedies ; and (a
circumstance which no one would have believed,
who had not learnt it from experience) the ut-
most danger will result to the patient.

Sydenham relates the cases of an officer in
the army, and of an apothecary, who died in a
very short time, in consequence of the use of
peruvian bark. The remedy had been adminis-
tered previously to a paroxysm, whence either
the fever was rendered more violent, or, which
is more probable, being quite smothered, the
febrile poison was thrown on the vital organs,
and thus destroyed their functions by its delete-

234

rious power. Hence arose sudden death, which,
perhaps, paroxysms much more severe would
not have produced. From what has been said,
it will not appear surprising, that, in cases where
intermitting fever has been removed by the bark
alone, some obstructions should remain behind.
The febrile poison which it too frequently suf-
fers still to lurk in the body, may be determined
to, and act injuriously on, any or all of the organs
or parts of the system. Hence there is no doubt,
but the mania which Sydenham speaks of as
having succeeded a quartan fever, arose from the
relics of the fever, or of the febrile poison, being
thrown on the brain.

CHAP. XIV.

Of the precautions necessary to prevent mischief in the
administration of the peruvian bark.

FROM what has been said, it follows, that
the peruvian bark is not a remedy of such a na-
ture, as ought to be immediately exhibited in
every case of intermitting fever. Yet what we
have said respecting its virtues, is incontro-
vertible and certain. Those fatal events which
are charged to its account, very rarely occur.
All the unfavourable accidents which are urged
by the common people, and by certain physici-
ans, as arguments against this remedy, are to be
attributed to the imprudence of those who have
made use of it ; for if it be not taken by the sick
till their systems are properly prepared for it, by
previous remedies, these accidents are not to be
dreaded. We have, therefore, treated of them,
only with a view to prevent the use of this ex-
cellent specific from being turned into abuse.

236

Acting on the same principle, we will now lay
before the reader, those cautions necessary to be
attended to in its administration.

It will be prudent and wise in us, to take na-
ture for our guide, in the cure of intermitting fe-
vers. These diseases occur about the com-
mencement of autumn ; as that season advances,
they become, as it were, more fixed ; they are in
their highest state of confirmation, or obstinacy,
during the winter ; but on the return of warm
weather they terminate of their own accord. By
the warmth of the season the system is relaxed,
and the pores of the skin opened. To effect the
cure of intermittents, remedies ought to operate
in the same way ; or, which amounts to the
same thing, the body must be subjected to a kind
of summer temperature ; medicines of gentle
warmth must be taken internally, in order that
the perspiration may be promoted. Such is the
effect of this cutaneous evacuation, that, provided
it be kept up to a sufficient degree, during the
exhibition of the bark, a cure will certainly be ef-
fected. But, on the other hand, there is no
ground to hope for this, if the skin be dry.

But it may be laid down as an established
principle on the subject, and as one which em-
braces every thing necessary in the use of the
peruvian bark, that intermittents cannot be cured

237

by it, unless the functions of the internal parts of
the system be in an active and healthy state. If
the viscera be in any measure diseased, this re-
medy will be exhibited in vain. Should the dis-
ease even be suspended by it for a time, it soon
recurs again with as much severity as before.
On die other hand, if the internal organs be in a
sound and healthy state, the fever will be so easi-
ly removed, that it will be scarcely necessary to
join any thing else with the bark. It will in ge-
neral, under such circumstances, prove suffici-
ent of itself for the cure of the disease.

It must be the earnest endeavour of the prac-
titioner, therefore, to prevent any stagnation of
blood in the viscera. Hence arises the necessity
of blood-letting, of which we have already spoken
in such favourable terms. Equally attentive
must the practitioner be to promote the secre-
tion of bile ; for while that secretion goes on
actively, remedies will the more easily reach the
cause of the disease ; all the symptoms will be
more mild, both the cold and the hot fits will be
less violent, the patients will not be exhausted by
such profuse sweats, nor will the humours ac-
quire such a degree of acrimony. The several
symptoms will be still more alleviated, and the
state of the system be rendered more promising,
provided the pores be kept open and the skin
moist.

238

The functions of the stomach must be very
particularly attended to. If that organ be dis-
ordereJ, or only loathe food, there will be no
ground to hope for a cure of the fever by the
use of the peruvian bark. On the other hand,
the disease even acquires fresh strength from the
exhibition of that remedy; a sense of pain and
heat is excited in the stomach by it, which is
usually extended even to the lungs. But if the
appetite be good under the use of the bark, that
is an infallible sign that the patient will soon be
restored to health. At least very few instances
occur, where persons with keen appetites are
not soon relieved from the disease.

The intestinal tube is the third part, to the
functions of which attention should be paid. If
it be not in a healthy condition, the cure of
the fever will, as was formerly mentioned, be
very difficult. Indeed it is in vain to attempt
the cure of intermittents, if the bowels be not
kept open. To the peruvian bark, therefore,
the practitioner should always add some lenient
purgative ; lenient, I say, and such as may but
gently excite the peristaltic motion of the intes-
tines : for if an acrid and highly stimulant pur-
gative be given, such commotions may be ex-
cited, as will greatly augment the febrile heat ;
or such a profuse evacuation may be occasioned,
as will .carry off entirely the febrifuge qualities

239

of the bark, and thus prevent the success of the
remedy.

There occurs at times, either in consequence
of affections of the foregoing parts, or from some
other cause, a state of the system which is no less
unfavourable to the cure of intermittents. Some-
times, for instance, in these fevers, the sick are
parchedas it were, by a very acrid or pungent heat.
If, in such a state of things, the peruvian bark be
exhibited, it never proves successful. If its use
be persevered in, it will even become highly in-
jurious ; the febrile heat will be rendered more
intense, the humours will become extremely
acrid, and the force of the paroxysms will be
augmented. The fever may even assume a con-
tinued form, or if it be by chance removed, there
will be reason to apprehend the occurence of
those other numerous and troublesome symp-
toms, of which we have already spoken. Nor
can we, indeed, while there exists a burning
heat in the internal parts of the body, expect
any thing else from an astringent and bitter re-
medy. Its use is adding stimulus to stimulus,
and fire, as it were, to fire.

So frequently does this fire or burning heat
prevent the cure of intermittents, that as often
as I have observed these diseases refusing to
yield to the peruvian bark, particularly at their

240

commencement, I have almost always suspected
the existence of such a heat in the viscera. In-
fluenced by this suspicion and by long experi-
ence, I have uniformly been of opinion, that, un-
der such circumstances, the use of the bark
ought to be laid aside. In cases of this descrip-
tion, I have been in the habit of prescribing
cooling and opening injections, by which, in a
short time, all the symptoms are rendered mild-
er, and the fever so changed as to be easily re-
moved by the febrifuge powers of the bark. Even
in the most obstinate intermittents, this remedy,
when properly managed, has seldom failed with
me to produce a cure.

Hence, we see, with what little judgment
those physicians act, who, in their attempts to
cure intermittents, begin immediately and indis-
criminately with the peruvian bark, or who
throw in vast quantities of that remedy in a short
time. Sometimes, indeed, it may prove inno-
cent and even produce a cure. It has remov-
ed intermittents when exhibited to the amount
of an ounce in six or eight hours. But an at-
tempt to cure these diseases in this way, is not
always safe. A sensation of weight and tight-
ness is immediately produced in the stomach ;
the thirst is rendered more intense; pains arise
in the hypochondriac regions ; a burning heat is
excited. All these symptoms terminate, finally,

241

in some other disease, such as jaundice, an en-
largement of the spleen, or a continued fever,
which is sometimes less dangerous than the other
symptoms.

From what has been said, it plainly appears,
how rash and hazardous it is, to administer bark
at the commencement of the cold fit. Some-
times, indeed, this remedy removes intermit -
tents when mixed in wine or spirits of wine :
it accomplishes the same object, as we have al-
ready observed, when given in conjunction with
jalap or agaric. But lest any one should be led
into an error by this treacherous experience, let
it be held in remembrance, that intermittents are
frequently cured by very dangerous medicines.
But as it would be the height of madness to trust
to such deceptious experiments, so it would be
no less irrational to be led by similar arguments,
to the exhibition of peruvian bark in the cold
stage of fever.

What can be expected from a remedy of
this kind, whilst, as was formerly mentioned, the
system is, in all its parts, labouring under a con-
striction ; whilst the stomach can scarcely bear
even warm water ; whilst the blood is stagnating
in the vena porta?, in the auricles of the heart,
and in the lungs themselves ? Surely by the use

of such a remedy, under such circumstances,

i i

242

great anxiety or uneasiness would be produced ;
the force of the cold fit would be increased ; and
the violence of the paroxysms augmented. But
those physicians have been still more unfortu-
nate, who have ventured to administer essential
oils and other more heating substances during
the cold fit ; for by such practice death has been
sometimes suddenly produced.

By this rash mode of treatment, the salutary
efforts of nature are necessarily suppressed. We
formerly intimated that, the febrile poison is ex-
pelled by a kind of crisis. Galen observed this
crisis, and asserted that evidences of it manifest-
ed themselves in a very early stage £>f the dis-
ease. These evidences appear in the urine ; not
indeed, in alateritious and gross sediment, which
is always the sign of a violent fever ; but in a
white and very thick sediment. The cause of
the fever is also carried off by the bowels and
the pores of the skin.

Many physicians are firmly of opinion, that
intermittents are removed by peruvian bark,
without any crisis ; for that remedy appears
sometimes to destroy them as if by a single blow,
and that without any evacuations either from the
bowels, the urinary organs, or the pores of the
skin ; at least many practitioners assert, that
they have not observed any such evacuations.

243

But it is very doubtful whether or not they have,
in these cases, been accurate observers of na-
ture. When intermittents are cured by the
pcruvian bark, the crisis is not always very per-
ceptible. But it is certain, that unless the na-
tural evacuations, which had been checked or
disturbed, be restored, a perfect cure will not be
obtained. But this restoration is a kind of crisis.
That such a crisis does, therefore, occur, is a
truth which no one will either deny or doubt,
who has examined the subject with the neces-
sary degree of attention.

CHAP. XV.

Of the method to be adopted in the use of the Peru-
vian bark.

WITHOUT any further preliminary re-
marks on the subject, we will now proceed to
mention that method for the use and exhibition
of the peruvian bark, which is founded on long
experience, and is fairly deducible from what
has been already laid down.

Having premised the necessary preparative re-
medies, such as blood-letting, evacuation of the
stomach and bowels, and the use of aperients, the
bark may be exhibited alone in doses of, from a
drachm to a drachm and an half, at such intervals
that four or five doses, or more or less, accord-
ing to circumstances, may be taken during the
period of intermission. In this way, the sick
being at the same time under a proper regimen,

245

many intermittcnts have been, and still are cured.
When the bark was first introduced into practice,
the mode of using it was very different. At that
time, as soon as the bark was taken, the patient
was directed to take also some solid food, a prac-
tice which is alike inconsistent with both reason
and experience. The sick should be supported
principally by broths, until the close of the fever,
when a more generous diet may be allowed.

In the mean time, strict attention must be
paid, to ascertain whether or not the medicine
agree with the stomach ; whether or not it ex-
cite an appetite for solid food ; whether or not
the surface of the body in general be moist ;
whether or not the bowels be in an open state ;
and, lastly, whether or not the natural colour be
restored to the urine. If there be any thing
amiss on either of these scores, gentle purga-
tives, aperients, and refrigerants must be called
in to the aid of the bark. In such cases, vitriol-
ated tartar or some other cooling neutral salt
combined with the bark will answer an excellent
purpose. To avoid the necessity, however, of
recurring to these remedies during the course
of the cure, they ought not to be omitted in the
beginning of it.

But as the bark in powder is oftentimes dis-
agreeable to the stomach, as we have already

246

mentioned, and as the primae viae may for a cer-
tain time, be troubled by bilious and very acrid
humours, there is another method in which I
have thought proper to prescribe this remedy,
and that with much advantage. After cleansing
the stomach by an emetic on the day of inter-
mission, I order a strong decoction of the bark
to be administered in the form of injection, in
the quantity of four or five ounces every two
hours. This preparation both acts as a febri-
fuge, and tends to keep the bowels in a free and
open state. The dose may be increased or di-
minished according to circumstances.

In some constitutions the peruvian bark pro-
duces severe and copious purging. When this
is the case, its purgative effect must be prevented
by laudanum, else its febrifuge qualities will pass
off by the bowels, and not enter the systematall.
Besides, it may even irritate the bowels to such
a degree, as to add to the violence of the fever.
Its purgative effect, however, must not be check-
ed if it move the bowels only five or six times
a-day, and that only during the first or second
day of its exhibition. I have never known such a
moderately purgative effect to have any influence
in preventing a cure. On the other hand, it
even contributes greatly towards it, by carrying
off whatever may be left behind of the depraved
humours. But should the bark continue to purge

247

for several clays, this effect must be moderated,
else it will debilitate the system of the patient.
Still, however, this remedy will remove inter-
mittents the sooner, provided it continue to
keep the bowels open to a moderate degree.

Intermittcnts do not, in general, terminate
immediately by the use of these remedies. Some-
times thesubsequent paroxysm may be even more
severe, and that, perhaps, in consequence of the
tumult excited in the system by the purgative
effect of the medicine. In general, however, the
paroxysm is mitigated in force, and sometimes
does not occur at all. At least the third pa-
roxysm will almost always be prevented. By
pursuing this method, therefore, intermittents
may be cured both speedily and safely. Hence
those physicians have erred greatly, who have
not hesitated to assert, that the action of pur-
gative medicines is unfavourable to the effects of
the peruvian bark.

AYe must not desist from the use of febri-
fuge remedies, as soon as the fever terminates.
The cure must be confirmed, and the febrile fo-
mes entirely eradicated. This is the more ne-
cessary to be attended to, in as much as during
the first stages of the cure, the patients frequent-
ly experience slight affections of the head, yawn-
ings, something of chilliness, sleepiness, or some

248

other diseased sensation of body. These, indeed,
are, as it were, only so many remembrancers of
an evil that is past, but they may break out into
a real fever similar to the original one. It is
necessary, therefore, to continue the use of the
bark, till the cause of the disease be entirely
vanquished. The precise length of time during
which the administration of this remedy ought
to be continued it is impossible to determine ;
that depends on many circumstances which
are very different in different patients.

In the mean time, certain general principles
may be laid down, to which all directions on the
subject are reduceable. Thus, the bark ought
to be exhibited in certain doses, for six or eight
days after the disappearance of the fever, and
then gradually diminished daily, or thereabouts.
It may, at length, be laid aside entirely, and that
sooner or later, accordingly as the different parts
of the system are more or less perfectly restored
to their healthy functions. Finally, the patient
cannot be considered secure from a return of
the disease, while there is any deficiency in the
secretion of bile, or the openness of the bow-
els, or any thing wrong in the colour or quantity
of the urine.

Such is the method, which, to many physi-
cians as- well as to myself, appears preferable to

249

all others. There are, however, other modes
of exhibiting the bark, from the merits of which,
I would not wish to detract. Different methods
may have their peculiar excellencies, as being
better accommodated to particular constitutions;
some, for instance, to tender and delicate habits
of body, and others to such as are more robust :
some remove disease more speedily, while others
accomplish the same end by a slower process.
There are, however, innumerable cases in which
we are forced to depart from the usual practice.
Hence, we must accede to the apparently contra-
dictory opinions published by different physici-
ans ; they have all employed the proper specific,
but the method must be different according to
the constitutions of the sick and the nature of
the disease ; and it is right that every one should
be governed by his own experience.

There is no other method, however, prefer-
able in the cure of a double tertian to that which
we have prescribed. The only difference be-
tween simple and double intermittents is, that
the latter are superior in violence, and are
characterized by shorter intervals between their
paroxysms. From these two circumstances,
then, must be deduced the differences that
necessarily exist between the proper modes
of treating double and single intermittents.

250

The more violent the fever, then, and the
greater the danger that accompanies it, the great-
er circumspection it calls for in the exhibition
of the first or preparatory remedies. The more
strict, for instance, must be the patient's diet;
the more diluents must he use; the more must
the febrile heat be moderated ; and the more
strictly must the use of aperients be enjoined ;
but, in particular, the more copious must be the
evacuations from the stomach and bowels, m or-
der, that whatever might tend to increase the ac-
tion of the febrile poison may be discharged.
At length recourse must be had to the bark.
This remedy, however, must be deferred till a
later period than in a less violent disease, unless
the most urgent circumstances should call for a
different procedure.

If there be any form of intermittent, in which
the bark is not to be immediately exhibited in
substance, it is more especially the double ter-
tian. In this disease it is better and safer to em-
ploy a decoction of the bark', with some cooling
and purgative neutral salt dissolved in it. The
production of acrid and putrid humours is then
more copious ; whence results the necessity of
a remedy calculated both to evacuate, and to
counteract fever. In as much as the paroxysms
in this disease press closely on each other, it is
necessary to give a glass of this decoction every

251

second hour. We do not, however, lay this
down as an invariable rule. But it is most cer-
tain, that the practitioner must here perform in
a shorter interval, what he usually performs in a
longer one, in cases of simple intermittents.

To this mode of treatment a double tertian
seldom fails to yield. By the exhibition of the
preparatory remedies alone all the symptoms are
mitigated, and sometimes the disease declines
into a simple tertian. But even in case things
should not go on so successfully as this, still by
persevering in the same mode of exhibiting the
bark, the disease will begin to be removed. In
a double tertian the fevers that constitute it aYe,
for the most part, cured in succession, or one at
a time. Thus, as we formerly mentioned, one
of the two tertians disappears immediately, while
the other still remains. When both shall have
disappeared, then a simple decoction, or the bark
in substance, may be exhibited, and that either
with or without some purgative salt, as circum-
stances may require.

CHAP. XVI.

Whether or not a quartan fever requires a mode of
treatment peculiar to itself

THE foregoing considerations relate to in-
termittents of every kind. We must now en-
quire, whether or not the quartan fever calls for
a mode of cure peculiar to itself. Previously to
the discovery of the peruvian bark, this disease
was considered as the opprobrium of physicians
and the torment of patients. Even at the pre-
sent day, it is believed by many, not to yield
to that remedy. Although, say they, it often-
times seems to be cured by the bark, yet it fre-
quently disappears only for a certain time. It
oftentimes continues throughout the winter, and
on the occurrence of the spring or summer, is
cured by the favourable influence of the weather,
rather than by the febrifuge virtues of the
bark.

255

It must, indeed, be acknowledged, that the
quartan lever possesses something peculiar to
itself. It differs from other forms of intermit-
ting fever particularly in this, that it appears to
take deeper root in the system than they do, un-
less it be checked at an early stage. But if it
be of recent origin, there is no doubt but it will
yield to the mode of treatment already mention-
ed, and that as readily as any other form of in-
termittent. As it may. however, degenerate
into a more obstinate disease, there are certain
precautions which should be used to prevent
such frequent relapses in it, to the reproach of
both the peruvian bark and the medical pro-
fession.

Unless the symptoms of the disease be very
slight, a strict diet must be firmly enjoined, al-
though the intermission of two days which oc-
curs between the paroxysms may not seem to
require it. Even this will not succeed without
blood-letting. So important a remedy is blood-
letting in quartan fevers, that it almost immedi-
ately reduces their violence, and many of them
cannot be cured without it. Emetics are no
less essential in the cure of the disease ; if they
be neglected, the febrile fomes will for the most
part remain in the system. Purgative remedies
are not altogether so necessary, because the ac-
cumulation of vitiated humours is not in general

254

so abundant in diseases of this description. It is,
notwithstanding, adviseable to keep the bowels
in a laxative state.

These precautions being attended to, there
is no doubt but the fever will be subdued, pro-
vided it be treated in the manner which we have
laid down. As it is, for the most part, however,
extremely obstinate, a larger portion of the bark
must be administered. For the same reason, it
is better to mix with that febrifuge some other
remedies of a penetrating nature. Certain aro-
matic substances mixed with vegetable alkali,
are sometimes exhibited with the best effects.
Cascarilla, in particular, is a very powerful re-
medy in the treatment of quartan fevers. This
mode of practice is sanctioned by daily experi-
ence, as well as by the authority of the ancients,
who were in the habit of prescribing the more
heating kind of remedies, not constantly, in-
deed, but in certain cases.

It is particularly in quartan fevers that the
peruvian bark, mixed with the lesser centaury
or agaric in powder, maybe exhibited with great
advantage. Even in persons of delicate, but
more especially in those of robust constitutions,
and in such as were subject to no diseases of the
viscera, I have oftentimes used the following re-
medy, namely, Pulv. Cornachini gr. xxiv :

255

Agarici. gr. xv. Sal Amnion, one drachm :
Cort. Peruv. four drachms, M. f. Electuar :
The mode of administering this preparation is,
to give the fourth part of it to the patient every
third hour.

I have known a great many quartans cured
by this remedy alone, although they had already
run on for two or three months. It is necessary,
however, to persist several days in the use of it,
taking care only to diminish, if requisite, the
quantity of the purgative medicines. In the
mean time, let the patients use ptisans of aperi-
ent and gently cordial qualities. It will also be
adviseable to administer to them moderate doses
of nitre, both for the purpose of increasing the
urinary discharge, and also of moderating the in-
ternal heat, which may possibly be produced by
the foregoing remedies.

After the quartan fever has yielded to the ac-
tion of these remedies, the use of the bark must
not be immediately relinquished. In conse-
quence of the just apprehension of a relapse, this
febrifuge must be continued for a very consider-
able time. If neutral salts and chalybeates be
combined with it, they render it a prophylactic of
still higher value. This compound preparation
restores tone to the system, removes obstruc-
tions, and promotes the secretion of the bile.

256

But although all these acrid and heating ar-
ticles, of which we have treated, be almost infal-
lible remedies against quartan fevers, they can-
not be administered to everyone labouring under
it. Those persons whose constitutions are weak
and irritable cannot bear their action. In such
patients, therefore, the preparatory remedies
are to be exhibited with greater caution than in
others, and the peruvian bark must be used in
the same manner as in simple tertians, that is,
combined with gentle purgatives and aperients.
Sometimes the heating quality of the bark is to
be moderated. This may be done by making it
into a decoction along with borage and bugloss,
and adding to the liquid thus prepared, a quan-
tity of nitre or arcanum duplicatum.

In persons advanced in years, still further
precautions are essentially necessary. In such
subjects quartan fevers are more dangerous, be-
cause the vital principle is sometimes overwhelm-
ed by the cold fit. If, therefore, the violence of
the cold fit be very great, a return of it must, if
possible, be prevented. This end will be most
likely to be attained by emetics, followed imme-
diately by a copious use of the peruvian bark.
But, as in old age, the different parts of the body
are less permeable, and their excitability less
keen, the activity of the bark must beencreased
by some stimulating aromatic and penetrating

257

salt. These additions are still more necessary in
the winter season.

To what is here said, respecting the use of
bark in quartan fever, I must add, that I am ac-
quainted with what I consider as a certain reme-
dy against the obstinacy of that disease. I allude
to warm mineral waters possessing purgative
properties, which have produced a perfect cure,
when all other remedies had been tried in vain.
Many have been cured under these circumstan-
ces by the waters of Bourbon. The waters of
other places have also produced the same effect.
Several persons, who, after the last war in Flan-
ders, retained the relics of obstinate quartans
and even tertians, were restored to health by
these, when all other remedies had completely
failed.

CHAP. XVIL

Of impediments arising from previous affections of
certain parts of the system, or from different tem-
peraments.

THE foregoing directions cannot be strict-
ly followed in all cases. Such, frequently, is
the nature or temperament of patients, the con-
stitution of some particular parts of the system,
the nature of the fever itself, and the variety of
symptoms, that difficulties occur on all hands.
To remove these difficulties, therefore, the prac-
titioner must pursue a different course, or ra-
ther, he must vary the course already pointed
out, so as ultimatelv to attain the cure of the
disease. The use of the bark must be accom-
modated to the various impediments which are
thrown in the way, whether these impediments
exist in some particular part, or be spread
throughout the whole body.

25§

The stomach itself oftentimes rejects the
bark. It cannot, for instance, bear the taste of
this remedy, though by no means very disagree-
able. To remove this difficulty, Fuller prepared
a draught composed of bark, syrup of cloves,
and some cordial distilled water. In this pre-
paration there is nothing to offend the stomach,
and the only thing to be dreaded is, lest it may
prove too highly stimulant. To prevent that,
let some cooling, and aperient ptisan, with nitre
dissolved in it, be given at the same time.

The same objection exists against an infu-
sion of bark in generous wine. To render the
preparation less disagreeable, some physicians
use Spanish wine, but direct the infusion after it
is made, to be boiled a little. They are of opi-
nion that, by this process the wine loses part of
its native strength, and may be prescribed with
safety. If any wine, however, be admissible, it
is particularly Rhenish wine, as being more ape-
rient and less stimulant. But, as I have very
frequently mentioned, remedies of this kind are
always too heating. They may answer a better
purpose in fevers that have nearly worn them-
selves out, than in such as are more violent and
of recent origin. In this latter description of
fevers, a watery infusion of the bark, holding
some neutral salt in solution, forms a more suit-
able remedy.

260

But an impediment to the use of the bark fre-
quently arises, not only from the repugnancy of
the stomach, but from its injured functions. An
obstinate vomiting sometimes forbids the use of
this remedy. To remove this difficulty Syden-
ham was in the habit, after the manner of Ri-
verius, of exhibiting lime juice and vegeta-
ble alkali, and afterwards liquid laudanum for
the purpose of allaying irritation. Others,
pursuing a bolder practice, have attempted the
cure of fever by exhibiting the bark combined
with opium or laudanum. But if the violence
of the fever be not too great to be borne with
safety by the patients, my first step is to remove
the affection of the stomach, which being done,
the general disease can be the more readily sub-
dued.

But the intestinal tube no less than the sto-
mach oftentimes presents difficulties to the cure
of intermittents. In either case the sick may be
relieved in the same way, namely, by exhibiting
the bark in the form of injections. When given
in this way, however, it has been observed to be
more serviceable to young persons than to adults.
But it will do little or no good, unless it be re-
tained for a considerable time in the colon and
rectum. It will be very readily discharged, par-
ticularly if a diarrhoea exist. In such a case,
recourse must be had to narcotics, which may

261

be given in the decoction of the bark. The
proper doses of these remedies arc the only
points that now remain to be determined. Great
care, however, must be taken not to give too
large a dose of narcotics, else the issue will be a
deep stupor.

Difficulties arise from the state of the lungs,
no less than from that of the stomach. When
the lungs are tender and irritable, and the sick
subject to a spitting of blood or a troublesome
cough, they appear incapable of bearing the pe-
ruvian bark. But it is to be remembered, that
the disease itself is more injurious to this pec-
toral affection than the action of the remedy.
The bark must, therefore, be employed, but
care should be taken at the same time to admini-
ster lenient and demulcent medicines along with
it. For this purpose, I am in the habit of adding
to the decoction of it, the root of the althea, or
the flowers of the poppy. In the case of a fe-
male, who had been attacked bv a verv severe
and incessant cough, I employed these demul-
cents with the greatest advantage ; for the
cough and fever were removed at the same
time.

In cachectic and hypochondriac patients,
the bark must be used with precautions suited
to the particular nature and character of the ex-

262

isting affections. In persons of the latter de.
scription, some of the viscera are diseased, in
consequence of which, the nerves are affected
with irregular and preternatural motions. If,
therefore, heating substances be administered, if
the peruvian bark be given alone, without any
previous preparation, an intense degree of heat
is excited, and a constriction is produced in the
diseased viscera* Hence, emollients, gentle laxa-
tives, aperients, and refrigerants, ought both to
precede the use of the bark, and also, to accom-
pany it. If a different mode of treatment be
attempted, the fever will be rendered more obsti-
nate and severe.

Difficulties equally great arise in the cases of
chlorotic females, or such as labour under men-
strual irregularities. Subjects of this descrip-
tion are with difficulty relieved from intermit-
tents, because they are affected by two diseases.
The practitioner must begin by administering
emetics to them, as such remedies are no less
efficacious in the removal of the original affec-
tion than of the fever itself. As the stomach is
always disordered by a suppression of the ca-
tamenia, a remedy which will excite that or-
gan to severe action, cannot fail to be of ser-
vice. A perients are also of advantage in such
affections.

263

In children the cure of intermittents is at-
tended with no less difficulty. These young
subjects reject all medicines. It is peculiar to
them, however, that they are in less danger
than adults. We frequently see children of
every age, labouring for a longtime under inter-
mitting fever, and recovering at length without
any disagreeable consequences, and that with-
out medical assistance. But they would have
recovered more readily, had mild emetics been
administered to them in the beginning of the
disease. I have prescribed tartar emetic to
children of two years old. I am convinced
from experience, that this medicine operates
more mildly on them, than it does on adults.

The emetics will be productive of more sa-
lutary effects, provided they be followed up
by febrifuge remedies. The syrup of the pe-
ruvian bark will answer very well, particularly
if it be combined with the rob of elder berries.
This medical preparation, by acting as a mild
purgative, prevents in many children the neces-
sity of any other cathartic. But if it cannot
be employed, recourse must be had to absorb-
ents with rhubarb and cream of tartar. In young
children these remedies are real febrifuges : in-
deed, in many cases, it is scarcely necessary to
use any other medicines ; hence, let them be

264

administered as plentifully as practicable. For,
although so many children recover of their own
accord, yet in many others the abdomen swells,
the viscera are obstructed, and the liver becomes
greatly enlarged. These symptoms are render-
ed worse, if the bark be injudiciously adminis-
tered ; indeed, it may even produce them, if
they have not yet occured.

CHAP. XVIII.

Of impediments arising from the fever itself from the
injuries which it usually does to various parts of the
hody, and from an improper mode of treatment.

OTHER difficulties present themselves,
which arise either from the fever itself, or from
an improper mode of treating it. These may be
considered collectively or separately. Taken
collectively, or in a general point of view, they
may be reduced to an obstinacy of fever, and af-
fections of the abdominal viscera. In some
cases the fever absolutely refuses to yield to the
peruvian bark ; sometimes it is not in the least
affected by it, even when all the usual prepara-
tory medicines have regularly preceded it. The
efficacy of the peruvian bark appears to be dif-
ferent, according as the seasons are different. In
certain years it is attended with the happiest ef-
fects, while in others again it does more harm
than good. There are also certain places

in which it is a very unsuccessful remedy,

\r m

266

such, for instance, as marshy regions and
those bordering on the sea. There is a great
variety in the strength of the febrile poison.
When more acrid, it takes deeper root in the
solids and fluids of the body, and adheres to
them more closely, and with greater obstinacy.

When intermittents are obstinate or per-
verse as it were, it would be madness to perse-
vere in the exhibition of an useless remedy, when
it might even become hurtful. In vain do some
practitioners have recourse to larger doses, with,
a view to overcome the febrile fomes by force.
In such a case, either the cause of the disease re-
mains in the viscera, after the paroxysms have
been suspended, or, as we formerly mentioned,
fuel is added to the fire, and the fever is render-
ed more obstinate. It becomes necessary then
to desist from the use of bark, and to return to
that of diluents and aperients. But, above all,
an emetic must be administered. Many prac-
titioners in marshy countries err in this, that
they place too little dependence on emetics.
Such is the efficacy of these remedies against
fevers, that I have known many persons who
used them as prophylactics, to escape an at-
tack.

When intermittents are obstinate, many
considerations concur to convince us how im-

267

portant it is, not to abuse the peruvian burk.
From improper modes of treatment, various lo-
cal affections arise, which remain with the pa-
tients during the remainder of their lives. I
have known many of the most robust men,
who, after attacks of intermittents, have ex-
perienced various disorders of the princi-
pal functions of the system, and have fallen
at length into very grievous affections. Some
of these became melancholy and cachectic,
others were liable to obstructions, and not a
few, being never perfectly restored to health,
have at length fallen victims to their sufferings.
In some persons it has brought on a premature
old age.

In obstinate cases of intermittents many
things occur, and those of a peculiar nature, which
forbid the use of the peruvian bark. When this
remedy is employed, many persons as we form-
erly mentioned, experience a sense of heaviness,
a burning, and a constriction or tightness. But
these are so many certain impediments to a cure.
In such cases, one of two things exist, namely,
either there is some latent affection of the coats
of the stomach, which must be treated in a
manner suitable to its nature ; or (as usually
happens) that viscus is over- loaded with vitiated
humours, of acrid and highly stimulating quali-
ties. But these humours must necessarily be

268

expelled and changed ; hence again appears the
necessity of having recourse to emetics and al-
teratives. Nor must the bark be any more
employed, unless these remedies have preceded
it, or be administered along with it.

Similar impediments arise out of the state
of the duodenum, or the other portions of the
intestinal tube. Oftentimes the bowels are ren-
dered more costive by the use of the peruvian
bark. The stools burn as it were, are bilious,
of a yellowish-red, or of a black colour, so that
they sometimes even seem to corrode the patient's
linen ; if under these circumstances bark be exhi-
bited, the sick are sure to be injured by it. All bad
consequences may be guarded against by gentle
emetics, repeated if necessary ; after this, gen-
tle purgatives, refrigerants, and aperients, if con-
tinued a sufficient length of time, will effectually
cleanse the alimentary canal, and carry off the
whole mass of depraved humours. These are
the only remedies on which we can confidently
rely, in cases where the use of the peruvian bark
has produced an accumulation of such humours,
nor must that remedy be employed again, until
the state of the system be materially changed.

But we must look deeper into the very foun-
tain or source of all these impediments. They
almost always depend on the state of the liver.

269

If that viscus be oppressed from the beginning,
by the excessive violence of the fever, it would
be an error fraught with destruction to admini-
ster the peruvian bark ; and if its use be found
unfavourable to the secretion and excretion of
bile, it is to be no less carefully avoided on that
account : for if it be persevered in, an accumu-
lation of very thick and acrid bile will be form-
ed ; the liver will become parched as it were ;
the faeces will acquire a darker colour ; the
urine will become very red, and will deposit a
copious brick-dust sediment. But there is no
need of all these symptoms, to convince us that
there is some disorder in the functions of the li-
ver, which impedes the cure. If the counte-
nance be either livid or pale, or put on a yellow-
ish cast, even in cases where the fever appears
to have left the patient, it must be considered as
still lurking in the system ready to break forth
again.

To remove all these symptoms, the use of
the peruvian bark must be immediately relin-
quished, and medicines given for some time,
with a view to unlock the liver. For this pur-
pose, I have frequently used with advantage, the
depurated juice of certain saponaceous plants, to-
gether with that of borage and bugloss, holding
in solution a quantity of neutral salts, such as ar-
num duplicatum, &c. Such is the efficacy of

270

purgatives in affections of the liver, that I have
frequently removed them by the use of such re-
medies alone. Having accomplished this, which
was done sometimes sooner, and sometimes later,
I then had recourse with success to the peruvi-
an bark.

The impediment is still worse, if the abdo-
men become tense and hard, whether this effect
be produced by the action of the fever, or by re-
medies unskilfully administered. The cause
of this hardness is situated in the viscera just
mentioned. In consequence of the congestion
and obstruction which occur in these viscera,
the blood does not circulate freely through them,
and the other humours stagnate in them. Hence
arises a rigidity of the fibres, an astriction of the
intestines, and a plethora of the vessels of the
mesentery. But when these occurrences take
place, it is impossible to cure the fever without
their removal.

While these symptoms exist, the peruvian
bark cannot be exhibited without hazard. The
natural softness can be restored to the viscera
only by free and repeated evacuations. Nor
will the bark answer for this purpose, although
it may prove purgative, and even open the bow-
els five or six times a-day. For the siimulant
power of this remedy certainly irritates and ex-

271

cites heat, even while it solicits the intestines to
a discharge of their contents. Therefore, nei-
ther their fibres, nor the texture of the other
viscera are relaxed by its action.

i
Lenient purgatives contribute most to the
removal of this hardness of the abdomen. As
often as that symptom has occurred in my prac-
tice, I have cured the rigidity of the intestines by
cassia and other similar remedies. I have also
prescribed, at the same time, the juice of succory
and other herbs of that kind slightly impreg-
nated with salts. By the assiduous exhibition
of these remedies for a certain time, I have al-
ways succeeded in removing this hardness of the
abdomen, particularly in those cases of disease,
to the treatment of which I was called soon after
their commencement.

But in fevers of longer standing, this mild
treatment does not succeed so well. In them the
cachectic habit of body, and the hardness of the
abdomen must be attacked by remedies of great-
er strength. I have, therefore, oftentimes ex-
hibited a purgative mixture composed of senna
and some milder laxative, such as cassia, tama-
rinds, or manna ; I have then directed some
laxative and emollient beverage, with soluble
tartar dissolved in it. By this mode of treat-
ment I have generally accomplished my object,

272

arid have very often succeeded in removing even
the fevers themselves. But a cure effected in
this way is not to be fully confided in. After the
complete subsidence and softening of the abdo-
men, therefore, it ought to be confirmed by Pe-
ruvian bark.

This mode of cure is far more necessary
still, in case the abdomen be greatly enlarged.
Such an enlargement is not an unfrequent oc-
currence, even without any collection of water.
It takes place in various fevers, particularly in cer-
tain epidemics, and that sometimes in an early
stage of the disease. More frequently, however, it
does not appear till after the disease has run on
to a certain period. Not only the abdomen,
but the face, the arms, and the lower extremi-
ties swell. In this state of things the peruvian
bark must be cautiously avoided. Purgatives
and aperients, which we have so often recom-
mended, constitute here the principal remedies.*
Some reliance may be also placed on diuretics.
I have oftentimes cured both the fevers and the
swelling by the use of wine in which juniper-
berries had been infused, and to which the mar-
tial salt of Riverius and sal prunelle were added.

* Obstructions such as our author is here treating- of, appear
to be most certainly and effectually removed, by the exhibition of
mercury, till, a gentle ptyalism be produced Trans.

CHAP. XIX.

Of the cure of fevers which, having ceased for a timey
recur again, and also of certain symptoms that usu-
ally accompany them.

IF the impediments just mentioned be re-
moved, the fevers will be easily removed, nor
will any of the febrile poison remain behind. But
all patients have not the good fortune to be
thoroughly freed from this poison. In many
persons the paroxysms are only suspended for a
certain time ; either a very slight cause brings
them back again, or they return of their own ac-
cord. Thus, alternately disappearing and re-
appearing, these fevers are frequently protracted
for a great length of time.

To counteract this state of things physicians

have fallen on various expedients. One whilethey

have exhibited the bark in increased doses, and

another while mixed various articles with it, for

n n

274

the purpose of adding to its efficacy. It must,
indeed, be acknowledged that in a great many
cases this remedy thus variously exhibited does
succeed. When combined with the lesser cen-
taury it has been found capable of removing
many obstinate fevers. Mixed with purgatives
it has been no less efficacious. I have seen many
patients, who had taken large quantities of the
bark alone without effect, in whom a perfect cure
was afterwards effected in a short time, by this
same remedy when taken in combination with
neutral salts. Not only purgatives, but diluents
and aperients also, should accompany the use of
the bark.

But, these remedies failing, I have, when the
sick were willing to submit to it, adopted a
much more certain mode of cure. I have, im-
mediately ordered my patients to bed, as if they
were under an attack of a more serious disease.
I have then confined them to an extremely low
diet, and sometimes to water alone for several
days. I have next had recourse to the use of
aperients and gentle purgatives, and directed it
to be continued for a certain time. To this
treatment the fever has generally yielded ; or if
it did not entirely give way, its violence and ob-
stinacy have at least been greatly diminished. It
then readily yielded to the peruvian bark, if pro-

275

pcrly administered, and the patient had no ground
to dread a relapse.

This method is highly necessary in certain
fevers, which not unfrequently occur. In some
cases where the paroxysms have disappeared, the
pulse remains frequent ; it rises in force particu-
larly after the patient has taken exercise or food,
although he has not been intemperat in either.
In the mean time he does not appear to be in-
disposed, because he is, or has been, in the use
of febrifuge remedies. But if he be guilty of any
irregularity in diet ; if he return to his usual oc-
cupations ; and if, in addition to these things,
certain changes in the atmosphere occur ; under
these circumstances, the fever which seemed to
be removed, immediately recurs again. In vain,
then, will recourse be had to the bark, however
plentifully it may be exhibited. That remedy
will produce only fallacious and short lived sus-
pensions of the disease ; hence there will be an
absolute necessity of employing those auxiliary
means which Ave have just mentioned.

I would not, from what I have here advanced,
be understood to mean, that the fever must be
attacked by these same remedies, every time it
may recur. Sometimes very obstinate fevers may
be left to themselves ; if, for instance, they recur
in the winter, and the febrile poison cannot be

276

checked, it will be necessary to wait the arrival
of the spring. Even at other seasons, and in
certain temperaments, it becomes requisite to
relinquish entirely the unavailing use of reme-
dies. I have indeed seen, though rarely, inter-
mittents even in the summer season, so obsti-
nate as to resist all remedies. I have committed
such complaints to nature, taking care only to
regulate the diet of the sick, and to prescribe
such gentle remedies as might aid the viscera in
their respective functions. In some instances I
have derived more advantage from this mode of
practice than from any other.

So much for the mode to be pursued in those
intermittents, which remain obstinate, after, hav-
ing run on for a considerable length of time.
In recent cases, where the disease has been re-
moved and threatens a relapse, a different mode
of treatment must be adopted. When the
strength of the patient is not much impaired,
and the fever has not taken very deep root, it
will be most safe to return to the preparatory
remedies. Whence, if it can be done, both eva-
cuants and diluents must be administered. After
all remaining obstructions have been thus re-
moved, febrifuge remedies may be given with
advantage. Yet these must be varied in use ac-
cording as the fevers or the nature of the symp-
toms are various.

277

Some patients, for instance, though free
from fever and paroxysms, are subject to obsti-
nate watchfulness, or most acute pains of the
head. In such cases, the remedies must not be
relinquished, but rather urged with a zeal pro-
portioned to the urgency of the symptoms; for
we are not to consider the fever as actually sub-
dued, but only the force of the febrile poison as
thrown on the head ; after it has changed this
seat, the paroxysms return again as before.

In this situation of things, the febrile stimu-
lus must be drawn from the head. But in the
cases of most sick persons, I have observed that
this could not be done in any way better than by
blood-letting. By this remedy alone, however,
a cure cannot be accomplished. Hence I have
considered it safe and certain to have recourse
again to emetics; next I have directed laxative
and aperient drinks, which, with the occasional
addition of soluble tartar, I have generally found
sufficient for every necessary purpose.

Profuse sweats to which the patients are oc-
casionally subject, after the removal of the fever
or the suspension of the paroxysms, prove at
times no less troublesome. If this excessive
evacuation arises, as it usually does, from an im-
perfect cure, the disease must be treated n ith the
proper remedies. To this end, if it be not of

278

very long standing, if the strength of the patient
be but little reduced, or if those remedies which
ought to have been premised have been neglect-
ed, I generally have recourse to blood-letting,
and that with advantage. In such cases, there is
no doubt, but the viscera are subject to some
preternatural stimulus ; blood-letting, then, by
diminishing irritation, renders all things better.

But in addition to this, other remedies must
be administered, which seem better calculated
to put an immediate stop to the sweats. Eva-
cuants, indeed, draw off the fluids, which were
more slowly making their escape, through the
natural outlets of the body. But this avails
very little, unless attention be paid to the ob-
structions of the viscera, and the secretion and
excretion of the bile and urine be promoted.
Nor must we neglect such remedies as are cal-
culated to allay the internal heat. For, during
the flowing of these sweats, there generally ex-
ists a burning internal heat, and an acrimony
which stimulates the surrounding parts.

But these sweats which succeed the termi-
nation of a fever, may flow from a different cause;
such as the state of the blood, or debility of the
system. The affection must, then, be treated
in a different way. The bowels, indeed, as well
as the urinary passages should be kept open ;

279

but tonics, that is, remedies calculated to restore
the lost tone of the fibres, constitute the princi-
pal means of cure. Hence the pcruvian bark, or
a vinous tincture of it, are for the most part suf-
ficient. Sometimes bitter infusions taken along
with chalybeates answer every purpose. These
remedies will be the more effectual, if exercise
be called to their aid, which alone, with an at-
tention to regimen, is sufficient to restore the
strength of the circulation and the tone of the
vessels.

But there are other affections which are still
more difficult to cure. Thus, after the fever
has been checked, there sometimes remain con-
stant anxieties, a loathing of food, a heaviness,
and a loss of strength ; indeed the symptoms of
an ill- cured fever manifest themselves in all parts,
but particularly in the countenance, which be-
comes livid or of a yellowish colour ; all these
symptoms have occurred to me in practice, par-
ticularly during a certain epidemic, which com-
mitted great ravages in this place. On that oc-
casion, fevers which seemed to be perfectly
cured, generally recured again. It was then
with difficulty that the sick survived. Many
fell at length into a putrid diarrhoea, or a dysen-
tery. In some cases a copious effusion of blood
broke forth, and proved fatal to the patient.

280

In the treatment of this fever it was abso-
lutely necessary to reject the bark entirely. That
remedy seldom failed to render all things worse
instead of better. The heaviness, the prostra-
tion of strength, and the affections of the sto-
mach and liver, were relieved only by aperients
and deobstruents. The putrid diarrhoea could be
safely checked only by mild evacuants. The dy-
senteric symptoms required, also, a peculiar and
specific mode of treatment. Even after all the
troublesome symptoms had become milder, or
disappeared entirely, there were some practi-
tioners who still would not venture again on the
use of the peruvian bark. They waited till na-
ture or a change of the season should complete
the cure of the disease. But these physicians
had too great a dread of the effects of this reme-
dy. It could be safely used provided it was pre-
ceded by the proper remedies. Having previ-
ously prepared the systems of my patients for
its action, I then had recourse to it with the
greatest success. We have already treated of
the watery and flatulent swellings which occur
during the actual continuance of the fever. But,
as we have elsewhere mentioned, a swelling ve-
rv often attacks the lower extremities after the
febrile affection has terminated. Provided, how-
ever, the fever has been treated and cured in a
proper manner, nothing serious is to be appre-
hended from this swelling ; for the water cob

281

lectcd in the cellular membrane passes away of
its own accord, as the strength of the patient re-
turns. If, however, the water be in large quan-
tity, or if, in consequence of a laxity of the
fibres, it remain longer than usual in the
cellular receptacles, the exhibition of diuretics
and tonics becomes necessary.

On such occasions, a decoction of some bitter
aperient vegetables, holding in solution a quan-
tity of soluble tartar, is an excellent remedy. I
have also in many cases derived advantage from
the use of wine, in which juniper-berries had
been infused, and which contained at the same
time, in solution, a portion of the martial salt of
Riverius. But these are not the only remedies
that may be administered. There are others
which have been given with success, such as a
lixivium of broom ashes. There is but little
difference, however, between this remedy and
the febrifuge water of Riverius, which con-
sists of salt of tartar dissolved in common
water.

Such are the remedies which I have found by
experience to be efficacious in removing the re-
lics of intermittents, or certain affections which
are attendant on these diseases. If in prescrib-
ing these remedies, I have sometimes been silent

o o

282

respecting the peruvian bark, it is not, from such
silence to be inferred, that I meant to induce
practitioners to neglect the use of it. If the fe-
ver has not been cured in a proper manner, if
there be any apprehension that its fomes still re-
mains in the viscera, the use of the bark cannot
safely be dispensed with. When by the use of
other remedies the symptoms have disappeared
or become milder, the cure must be perfected
and confirmed by the bark.

CHAP. XX.

Of the cure of Malignant Intermittent*,

MUCH less must practitioners neglect the use
of the bark in the treatment of intermittents, if
they be of a malignant nature. But there is a
double plan of treatment which must be pursu-
ed in such diseases ; one of these must be adopt-
ed during the violence of the paroxysms, and the
other in their decline, or rather during their in-
termission. For as some of the symptoms are
foreign from the nature of the fever, these symp-
toms and the febrile cause call each for remedies
peculiar to themselves.

This circumstance, as formerly mentioned,
was observed by Louis Mercatus. That physi-
cian was the first who treated extensively of
these foreign symptoms, but Morton and Torti
have approached nearer to a proper method of

284

cure. We will briefly lay before the reader our
experience on this subject.

We will not treat separately of all the symp-
toms that occur, but only mention the principal
remedies by which they may be combatted.
When the head is severely attacked, when a de-
lirium occurs, or a kind of apoplexy, lethargy,
or coma oppresses the patient, a peculiar mode
of treatment becomes necessary. Blood-letting
has oftentimes been observed to remove these
symptoms like a charm. Nor is this remedy
less serviceable in those acute pains resembling
rheumatism which attack the limbs, back, &x.
in severe gripings or spasms of the stomach or
intestines, and m oppressions at the breast. In-
deed it may be used with advantage in all such
affections, provided the strength of the patient
be not too much exhausted.

In the apoplectic, lethargic, and comatose
state of fever, blistering must by no means be
neglected. Nor is this remedy less useful in
those paroxysms, in which the patients lie with-
out motion or sensation. But, although the
practice may to some appear less likely to prove
useful, I have even ventured to try the same
remedy in certain very acute pains ; for as these
pains are, for the most part, spasmodic, it is
practicable to effect a revulsion or derivation of

285

the morbid action from one part of the system
to another. I am convinced by experience that
blistering is also a very important remedy in
oppressions at the breast.

The use of opiates is no less recommended,
by the nature of the remedies themselves, by
experience, and also by the painfulness of some
of the symptoms. Indeed the rheumatic pains
in the limbs, are sometimes so severe as to call
for the immediate exhibition of these remedies ;
and in pains of the viscera, particularly of the
stomach and intestines, it would oftentimes be
almost criminal to neglect them. By opiates
vomiting and diarrhoea may be checked, which
sometimes bring the patients into the utmost
danger. It is in the mean time to be observed,
that opium should not be exhibited alone. It
ought to be mixed with aromatics, as in theri-
aca, and the liquid laudanum of Sydenham. It
may also be exhibited along with aether, which
is of itself an excellent remedy for oppression
and vomiting.

I will not here treat of diluents or demul-
cents, which contribute to allay irritation, and
the advantages of which are known to every one.
Nor is it requisite to dwell on the use of reme-
dies calculated to awaken motion and excite heat.
It must be ovious to every one, how nccessarv

286

these are in cases of prostration of the vital
principle, in great depression of the pulse, and
in a very obstinate cold fit where the surface
of the body assumes a marbled appearance. But,
that remedies may be exhibited with the more
advantage, no less regard must be paid to the
symptoms than to their cause. This cause is the
poison which vitiates the fluids, and disturbs
the functions of the system. It is necessary to
enquire, therefore, what may be capable of re-
sisting this deleterious cause, until its violence
abate, and an intermission ensue.

When the paroxysm has passed over and the
symptoms have become more mild, then is the
proper time to administer that febrile antidote,
the peruvian bark. This remedy may indeed
be exhibited in decoction, but there is reason to
apprehend that in this way it cannot be taken in
sufficient quantity. In a disease, therefore, so
rapid in its progress, recourse must be had to
the bark in substance, or rather, indeed, to the
extract ; nor need we be apprehensive of giving
it in too large doses. If the doses be small, they
will be insufficient for the end in view, which is,
to overpower, as it were, the febrile poison.
Hence, let the patient take a drachm of the ex-
tract of bark at a dose, and repeat this two or
three times during the intermission.

287

A question occurs here to be solved, name-
ly, whether or not purgatives ought to be mixed
with the peruvian bark ? These remedies, in-
deed, will not be amiss in affections of the head,
they may also be administered when the force of
the disease falls on the breast, as well as in rheu-
matic pains of the joints and limbs. The bow-
els ought, however, only to be kept gently open
rather than to be severely purged, lest the effi-
cacy of the bark should pass off in that way.
The force of the medicines must be particularly
directed against the febrile poison, whose impe-
tus is to be counteracted.

But there are various other affections in which
the bowels must not thus be moved. When the
stomach and intestines, for instance, receive
the whole force of the disease, the practitioner
must decline the use of purgatives. If a diarrhoea
exist, it must even be restrained. It would
be no less improper to administer purgatives in
cases where there is a prostration of the vital
principle, or where, during the cold fit, the heat
has retreated from the surface and extremities to
the internal parts of the body. In cases of this de-
scription, we must rather have recourse to aro-
matics, such as Virginian snake-root, in combi-
nation with the bark, that it may the more effec-
tually penetrate the recesses of the system, and
thus rouse it into action. For the same pur-

288

pose I have oftentimes administered the bark in
wine.

Another question occurs, and that of no less
moment, in as much as it relates more immedi-
ately to the danger of the disease. It is enquired
whether or not the physician must always wait
for a remission of the paroxysm in order to ex-
hibit the bark ? If, indeed, the febrile action be
not very intense, but, on the other hand, if there
be a prostration of strength and a debility of
pulse, if there be not great irritation in the sto-
mach or intestines, finally, if the force of the
symptoms will by any means admit of it, I know
no good reason why, in so doubtful a state of
things, the bark may not be exhibited either
alone or combined with some other remedies.
Although the symptoms usually intermit, yet
the degree and duration of the intermission are
both uncertain. In the mean time the danger is
great, and there is consequently a pressing call
for the exhibition of the antidote.

CHAP. XXL

Of the treatment of common remitting fivers, and
also of those of a malignant nature.

SO much for the treatment of intcrmittents ;
we will now pass on to the consideration of that
of remittents. These, as we have already re-
marked, are of various kinds ; or rather, they
vary with respect to their violence and their type.
They are often attended with unexpected and
dangerous symptoms. Hence, although they
originate from the same fomes, and the same
cause, it is requisite to enquire whether or not
they call for the same, or for different modes of
treatment. It is frequently difficult to institute
a mode of treatment, and this difficulty arises
from numerous causes.

The first thing to be attended to, is, the na-
ture and use of the remedies nccessarv to be ex-
hibited. The fevers arc continued, because

they are marked by no perfect intermission.

290

No other mode of treating them, then, immedi-
ately occurs, but that which is employed in con-
tinued fevers. But their nature and character
are opposed to all specific febrifuges, particular ly
to tonics, bitters, astringents, and such remedies
as excite heat. The peruvian bark appears,
therefore, to be improper in the treatment of re-
mitting fever. For if that remedy proves, for
the most part, injurious in genuine intermittents,
when their paroxysms are protracted, and their
violence is great, can it do good in a fever of a
continued course, although its violence may
sometimes abate ?

Yet as remittents belong to the same class
with intermittents, is it possible that they can
call for remedies altogether different ? Can that
medicine be improper in the treatment of remit-
tents, which is best calculated to subdue and eli-
minate their cause ? In order to reconcile all
these circumstances, which appear so inconsist-
ent with each other, we must look a little deeper
into the subject. We must enquire, for instance,
whether or not the symptoms of intermitting and
remitting fevers are so different from each other,
that they require to be cured by different modes
of treatment ?

The symptoms of these diseases do not, ex-
cept at first sight, appear to differ so greatly from

291

each other. In most respects the mode of treat-
ing intermittents and remittents is nearly the
same. For, as the bark does mischief if admi-
nistered in intermittents, during the actual ex-
istence of the paroxysms ; so also, in remittents,
if it be exhibited during the prevalence of the
paroxysms, it renders every thing worse. The
practitioner must, therefore, wait for the re-
mission, in order to administer this remedy with
advantage to the sick. Previously to its use,
the primae viae must be well cleansed, for if they
become turgid with fcecal matter, or if the bowels
be in a costive state, the fever will be encreased
in violence.

In the treatment of these diseases, there ex-
ists only this difference, namely, First, that in
remittents the fever only abates, and allows,
therefore, less time for the use of remedies to
counteract it, and, Secondly, that the febrile heat
is more intense, and the secretory functions less
free and active. The fomes of the disease will
consequently be eradicated with more difficulty,
because it will be removed only by slow degrees..
The action of the bark, however, both on it and
its effects is certain, though somewhat feeble; it
at least weakens its force, if it does not complete-
ly eradicate it. Let the impediments to the use
of the bark be done away, and that remedy will
be at length successful.

292

The efficacy of the bark is particularly mani-
fested in its preventing the paroxysms, or reduc-
ing their force. Hence, it appears, that if the
paroxysms be very severe, this remedy may be
advantageously employed against them. It may,
indeed, increase the heat of the body, and will
not immediately, as in intermittents, destroy the
febrile fomes. But the greater evil must be ob-
viated ; and the impetus of the fever will do more
mischief to the system, than the action of the
bark when used as a remedy for it. The state
of things is here precisely as it is in a case of
disease, consisting of a pleurisy joined to an in-
termitting fever. No doubt but, in such a case,
the peruvian bark may somewhat injure the in-
flamed lungs ; yet, as this remedy weakens the
force of the intermittent, and may do away the
danger arising from paroxysms, it ought to be
em cloved.

But there are certain principles by which the
exhibition of the bark ought to be regulated. It
should not be employed, unless the fever to be
removed be certainly of the intermitting kind.
It appears from the daily controversies of physi-
cians, how difficult a thing it is to discover the
real nature and character of fevers. Skilful
practitioners do not expect to derive any advan-
tage from the use of peruvian bark in febrile
complaints unless they be of the nature of

293

intcrmittents. But there are physicians of
less knowledge and abilities, who, as often as
they meet with a case of fever, marked by perio-
dical exacerbations, attempt its removal by the
peruvian bark. But as this remedy would be
hurtful in inflammatory fevers, although charac-
terized at times, by periodical and regular exa-
cerbations, will it be likely to prove less injurious
in various other fevers, which differ equally from
the nature of intermittents ?

In every fever, however, which derives its
origin from the fomes of intermittents, the pe-
ruvian bark is not calculated to check the pa-
roxysms. If in the spring, for instance, an in-
termitting fever be changed into a continued one,
or if it assume that form from the beginning, it
must be treated like a simple continued fever.
In this way, it is induced at length either to re-
mit or intermit ; or is sometimes, by such treat-
ment, even cured entirely. It is worthy of re-
mark, that I have oftentimes seen the fomes and
cause of an intermittent completely eradicated
by a continued fever.

In a similar manner must wc treat the double
tertian remittent, which is marked by regular
exacerbations, and never departs from its pro-
per type. Sometimes this disease runs on to
the eleventh, fourteenth, or twentieth day, and

294

is considerably violent even during the time of
its greatest remission. But while it prevails to
such a degree, the peruvian bark must not be ad-
ministered ; for it induces great heat, and adds
to the intensity of the fever. It is necessary to
wait, therefore, till its remissions become more
considerable.

There are some practitioners who have di-
rected a trial to be made of that remedy, on this
condition, that its use be immediately relinquish-
ed in case it does not succeed. Others again
conceive that it ought not to be exhibited earlier
than the twelfth day of the disease ; but both of
these classes are in an error. Uncertain reme-
dies ought not to be tried, nor should we fix a
certain period for the exhibition of remedies
which nature herself has not fixed ; our best
plan is to follow her as our guide, and to give
her such aid when labouring for her own relief,
as she seems to require.

Many remitting fevers occur, in which the
paroxysms or exacerbations come on with great
violence, and bring the sick into the utmost dan-
ger. In such cases the practitioner must pro-
ceed in a very different manner. The bark must
be exhibited with boldness. Nor must its use
be dreaded, because the remission is, perhaps,
rather slight. It will be sufficient if there be any

295

remission at all. It is only incumbent on the
practitioner to enquire, whether or not, any
thing ought to be mixed along with the bark,
and what assistance may be derived from other
remedies.

A mode of practice which I have generally
found successful, is, to exhibit an emetic on the
decline of the paroxysm, and after this to give
a febrifuge potion, consisting of bark, together
with some laxative and aperient remedies, so
prepared as to be capable of producing a speedy
effect. By such treatment as this, all the symp-
toms are generally rendered milder ; I say,
milder, for, in fevers of this description, we are
not to expect that the paroxysms will be entirely
removed, as they are in intermittents ; they de-
cline, for the most part, only in a very gradual
manner. Frequently, however, remittents of
this kind are changed into intermittents, not,
indeed, into tertians or quartans, but more ge-
nerally into the form of double tertians.

It more frequently, however, occurs, that in
fevers of this description, the paroxysms are so
protracted, that the preceding almost runs into
the succeeding one, leaving the intermission ex-
tremely short. Decoctions of bark, therefore,
should not then be n^ed, because they require
too long a space of time for their operation.

296

Recourse must consequently be had to the bark
in substance, or rather to the extract of bark. A
drachm of the extract is equal in strength to an
ounce of the bark in powder ; hence the neces-
sary doses may be more easily repeated, and
thus the patients placed in a state of safety. In
such cases, if in any, the extract may be mixed
with some cooling purgative salt. For the burn-
ing heat should be allayed, and if practicable,
the bowels kept open, for which purpose, the
remedies ought to be given in very large
doses.

The same remedy must be pushed to a still
greater extent, in those fevers where malignant
symptoms arise. When, for instance, the head
is very grievously attacked ; when an apoplec-
tic or lethargic state supervenes ; when the lungs
are greatly oppressed, or the abdominal viscera
affected with a very acute and excruciating pain

under these circumstances, I say, there is

the utmost danger in delay, nor can the lives
of the patients be sufficiently guarded in any
other way, than by a plentiful use of the peruvi-
an bark. When the febrile poison has disspread
itself throughout the whole system, this remedy
meets and extinguishes it, as it were, and, at
times, restores the patients from such a low
state, that they might almost be said to be raised
from the dead.

297

The mode of administering the bark depends
on the nature of the fever, the force of the symp-
toms, the longer or shorter duration of the pe-
riod of remission, and the laxity or costiveness
of the bowels. But amid such a variety of cir-
cumstances, it is impossible here to point out
what may be necessary for each particular case.
We can only say in general, that there is no great
difference between the proper treatment of dou-
ble tertians and malignant remittents, except
that in the latter, the remedies must, in the same
space of time, be given in larger quantities ; for
when the danger is so pressing, the febrile poi-
son should be subdued and eradicated as speedily
as possible.

It is indeed best to wait till the exacerbations
remit ; but there are cases in which the remis-
sions are scarcely perceptible. Then, indeed,
having first used the proper preparatory reme-
dies, the bark must be boldly exhibited. This
remedy is the less to be dreaded, in as much as
the pulse is for the most part depressed ; but if
it even were not depressed, still the bark must
by all means be used. In such a doubtful dis-
ease, it is, as we have already said, the sheet an-
chor of safety by which alone the vital principle
can be supported.

298

In the mean time a very special regard is to
be had to those symptoms, in which the whole
force of the disease seems to centre. It is, in-
deed, in counteracting these svmntoms that the
bark is so efficacious. But other remedies
should be also frequently exhibited in such cases.
From what we have said on the subject of ma-
lignant intermittents, the reader may readily col-
lect our sentiments as to the several means that
might contribute to a cure in the present instance.
What was there advanced may be applied to all
cases that usually occur in malignant remittents.
Indeed there is no other difference between the
two diseases, except that between the paroxysms
of malignant intermittents there is a longer in-
terval, and that during this interval the patients
are more free from fever.

For the better illustration of the method of
cure, I had prepared for publication a number
of cases. But it appeared best on reflection
that these should be omitted. There are not
two cases of disease precisely alike ; whence,
there are not two in which the same remedies
will produce precisely the same effects. It
seems most adviseable, therefore, to reduce to
certain general laws, all the facts which experi-
ence has brought to light, and from these, to de-
duce a mode of cure accommodated to the state

299

and condition of each patient. It is oftentimes
the fault of observers, that while they carefully
treasure up all facts that fall under their notice,
they seem quite regardless of the principles
which these facts are calculated to suggest and
support. But the establishment of just princi-
ples, besides being the proper and natural end
of observations and facts, is certainly what con-
fers on them their highest value.

THE END

KIMBER, CONRAD, tf CO.

HAVE FOR SALE, A FEW COPIES OF

A TREATISE
ON FRACTURES, LUXATIONS, AND

OTHER AFFECTIONS OF THE BONES,
BY P. J. DESAULT,

SURGEON IN CHIEF TO THE HOTEL-DIEU OF PARIS,

Wherein his Opinions and Practice, in such Cases, are stated and
exemplified.

EDITED BY XAV. BICHAT WITH PLATES.

TRANSLATED FROM THE FRENCH,

BY CHARLES CALDWELL, M. D.

WITH NOTES,

AND AN APPENDIX

Containing" several late improvements in Surgery
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Full text of "A treatise on the hidden nature, and the treatment of intermitting and remitting fevers; illustrated by various experiments and observations"

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